Jason Doe
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Jason Doe Texan Cardiovascular Institute PA Max Smith
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1. Member Info
2. Benefits

Basic Information

First Name *

Middle Name

Last Name *

DOB *

Gender *

Marital Status

Identification

Member ID *

Optum RX Number

SSN *

Member Type

Member Type *

Company

Dependent

Dependent Of

Broker

Name

Contact Information

Home Phone *

Cell Phone *

Work Phone

Alt Phone

Email *

Address & Residence

Residence Type

Apartment #

Address

City

State

Country

Zip Code

Plan Type *

Plan Information *

Price *

$

Monthly/Annual *

Final Plan Price *

$

Effective Date *

End Date *

Upload Plan PDFs

Plan & Rx Benefits *

Summary of Benefits and Coverage (SBC) *

Upload Digital ID Cards PDFs

Member Medical ID Card *

Pharmacy/OptumRx ID Card

Add Provider

Basic Information

Practice Name *

Tax ID *

Specialty Type *

Provider Type

In Network

No Yes

Primary Care Provider

No Yes

Contact Information

Office Phone Number *

Office Fax Number

Clinic Email *

Clinic Address

Address *

City *

State *

Country

Zip Code *

Provider Locator

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