LMS Registration Form

BeWellnm Assister Certification Request Form

This on-line form is for Plan Year 2024 Registration and Training for beWellnm Certification.
Registration

Your registration information will be used to begin the certification process and will used to inform consumers of your location.
Thank you for your interest in the beWellnm Assister Certification Training.

We are not accepting any new Assister Request forms for the Plan Year 2024 Training at this time. We will begin accepting new requests on 01/16/2024, please resubmit your form at that time.

If you have any questions or concerns, please contact partners@nmhix.com.

Returning Users:

Returning assisters should log in to access the LMS. You will be automatically enrolled in the certification training courses. If you need help reactivating your LMS account, please email us at partners@nmhix.com for instructions.

If you were not certified by beWellnm for plan year 2023, you are considered a new Agent, Broker, or Enrollment Counselor. Congratulations on taking the steps to certify for 2024! All new agents, brokers, and enrollment counselors should start by completing the form below. The information collected on this form will begin your registration process.

Important Tips:

- If you are not currently affiliated with an agency and would like to establish an agency, do not move forward. Please first reach out to partners@nmhix.com.

- Once your registration form has been processed, you will receive an email from partners@nmhix.com with instructions to access the training courses. If you have questions, reach out to partners@nmhix.com.

- * Asterisks indicate required fields.

The information collected in this form will begin your registration process for the beWellnm Learning Managment System.
Outreach

Be added as a resource to our outreach communications to receive notice of activities throughout the year, including phone calls campaigns, appointment scheduler, and face to face engagements at community events.
Title: *
Select the Assister title to indicate whether you are new Broker or Enrollment Counselor.
First Name
Last Name
Are you aligned with an organization or agency?*

YESNO
Agency or Organization Name *
Agency NPN Number
Agency NPN Number (Agents only)
Business Mailing Address This address will be shared with consumers as your local business office location *

Street Address

Street Address Line 2, Suite #

CityState / Province

Postal / Zip Code
Business City, State & Zip*

Street Address

Street Address Line 2

CityState

Zip Code
County
Mobile Phone Number*
Contact Phone Number
E-mail*
NPN Number*
National Producers Number
County
Home Address for ID Proofing This address is your personal address used to verify identity*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Date of birth for EC Background Check*
State issued Drivers License or ID Number for EC Background Check*
List the state issued. Example: NM 123456489
NM Counties Served: *
Example: Chaves, Dona Ana, Guadalupe, Luna, Lincoln, McKinley, or all 33 counties, etc.
Languages Spoken
Examples: Arabic, Chinese, English, Spanish, Vietnamese, etc...
Additional Comments
Time*

Hour Minutes

AM/PM Option
Date Submitted

MonthDayYear
Date
Should be Empty:

BeWellnm Assister Certification Request Form

Registration

Outreach