subject_line
Company Name
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Fax Number
*
Company Email Address
*
Website
# of Offices:
*
# of Employees:
*
Date of Formation
*
Head of Company
First Name
*
Last Name
*
Job Title
*
Phone Number
*
Email Address
*
Association Contact (if different)
First Name
Last Name
Job Title
Phone Number
Email Address
Please supply a 250-500 word description of your company which will be sent to members of IAMHP.
*
I’d like to receive marketing news alerts and other communications from IAMHP.
*
Yes
No
Are you BEP certified?
*
Yes
No
BEP Certificate (If Applicable)
Membership Options
*
Trusted Partner Annual Membership ($5,500/year)
Trusted Partner Annual Membership with Provider/BEP Discount ($4,500/year) NOTE: BEP Certificate must accompany this application to receive the BEP discount.
NOTE: ALL APPLICATIONS SUBMITTED AFTER OCTOBER 1 WILL BE CHARGED THE PRORATED PORTION FOR 4TH QUARTER OF THE CALENDAR YEAR
AND
THE FULL CALENDAR YEAR OF THE FOLLOWING YEAR.
Payment Information:
*
I authorize IAMHP to charge the following credit card in the amount indicated above for my annual Trusted Partner membership fee.
Payment will be mailed to: IL Assoc of Medicaid Health Plans, Attn: Jill Hayden, 3309 Robbins Road #428, Springfield, IL 62704-6587 NOTE: Membership will NOT begin until payment has been received and processed.
Card Number
*
MM/YY
*
CVV
*
Name on Card
*
Zip / Postal
*