Health Plans USA Contracting

Health Plans USA

Contracting Form
Name

First NameLast Name
Agency Name (if applicable)
Agent NPN (principal if agency) *
Agency NPN (if applicable)
Resident State (please select one)*
States (multiple selections using the "Ctrl" key and clicking)
Phone Number*
Please enter a valid phone number.
Email*
Please provide email address of Agent or Agency
Mailing Address (Business and Residential)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*

MonthDayYear
Date
SSN*
Agency EIN
Medicare Carriers

Aetna/SilverscriptAlignmentBannerBCBS of AZCentene/WellcareCignaDevotedElevance/Anthemeternal HealthGold KidneyHumanaHMSAKaiserMolinaPacific SourceRegenceSCANSelect HealthUHCVERDA Health Plan of Arizona
Medicare Supplement Carriers

ACE/Insurnace Company of North AmericaAetnaAflacBCBS of AZCignaHumanaPhysicians MutualPremeraUHC
ACA

Aetna(Banner/Aetna)Antidote HealthAmbetterBCBS of AZCareSourceCignaElevance/AnthemMedicaMolinaOscarUHCWellpoint
Life

GTLBOSS/Quote & Apply
Dental & Vision

AmeritasDelta DentalNCD (MetLife & VSP)
Travel

GeoBlueIMG Global
Pet

My Primary Pet Care
Carriers Not Listed
Click Here to Sign-up for our Life Insurance Portal
Click Here to Get Contracted for Dental ($10K Annual Max Benefit!)
RECEIVE A PERSONALIZED WEBSITE FOR QUOTING AND ENROLLING ALL LINES OF BUSINESS

To find out more and to request a demo, please reach out to Health Plans USA at:
- Contracting@HealthPlansUSA.com
- Direct: (480) 691.2500
Click the Links below to complete and sign required forms
Health Plans USA W9 and EFT Form
I have completed and signed the Health Plans USA W9 and EFT Form*

Yes
Health Plans USA Agent Agreement
I have completed and signed the Health Plans USA Agent Agreement*

Yes
Notes
Files (State Licenses, E&O, AHIP, FFM, etc.)*

Cancelof
SMS Consent
By submitting this form, you agree to receive conversational and support-related text messages from Health Plans USA, Inc. Message frequency may vary. Message and data rates may apply. For assistance, text HELP or visit https://healthplansusa.com. To opt out at any time, text STOP. SMS consent is not shared with third parties or affiliates. View our Privacy Policy and Terms of Service.
Should be Empty:

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

Health Plans USA

Click the Links below to complete and sign required forms