New Group Notification Form

GROUP INFORMATION

NEW

TERMINATE

CHANGE

Effective Date:	Number of Lives:
Group Number: Contact Name:
Address (OR or S.W. WA)  Physical:
Mailing:
Corporate:
Phone  Number:
Fax  Number:

MHN SERVICES REQUESTED

	Hospital Panel		Physician Claims Repricing
	Physician Panel		Worker's Comp MCO
	UR/QA		Directories
	Hospital Claims Repricing		Chiropractic PPO

TPA / PAYOR INFORMATION

TPA/Payor Name:
Contact Name:
Address:
Phone Number:
Fax Number:
Claims Address (if different from above):
Phone Number:
Fax Number:

BROKER INFORMATION

Agent / Broker Name:
Agency:
Agent / Broker Phone:
This form completed by:
Phone number:
E- Mail: