Managed HealthCare Northwest, Inc. 
      A Company of Legacy Health System and Adventist Medical Center

Broker Bonus Application

SOLD GROUP INFORMATION

Group Effective Date:

Employer Name: 

Address:

City:  State: Zip:

MHN or CareMark PPO enrolled employees:  

*
* 10-50 enrolled employees, broker will receive $50.00 one-time payment.
51 or more enrolled employees, broker will recieve $1.00 per employee, no maximum, one-time payment


PAYOR INFORMATION

Claims Payor:

Contact Person:

Phone:

2nd PPO?


BROKER PAYMENT INFORMATION
(Please allow 4 weeks for processing)

Payable to:

Mailing Address:

City:

 State: Zip

Taxpayer I.D.#:

Broker Name:

Phone:

E-Mail Address:


Thank you for your business!
 

Managed HealthCare Northwest, Inc.
1120 N.W. 20th Avenue, Suite 200
Portland, OR  97209
Ph: (503) 413-5800
Fx: (503) 413-5801

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