IAMHP Trusted Partners Program

Company Name *

Street Address *

Address Line 2

City *

State *

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 *