Billing Services Inquiry Intake Form

Benefit Allocation Systems, LLC

640 Freedom Business Center Dr, Suite 300

King of Prussia, PA 19406

ACA-Sales@BASusa.com

www.BASusa.com

(877) 885-3227
HubSpot Lead_Feeder Value to Identify Contact as Coming from this Form
ACA Reporting Services inquiry

For inquiries about BAS' Affordable Care Act (ACA) recordkeeping, compliance and reporting services
Organization Name
Your Full Name

First NameLast Name
Your Title
Your Phone Number
Preferred Phone NumberFormat: (000) 000-0000.
Your Email

Confirmation Emailexample@example.com
ACA Services Interests

Other
Where is Your Data?

Other
Who provides your ACA Services Currently

Other
How Many Full-time and Part-Time Employees
Alert

Employers with 50 or more full-time employees must report, even if they don’t offer healthcare coverage.

Employers with less than 50 full-time employees must report only if they offer self-insured health coverage.

If the employer is part of a controlled group, it must combine the employees of each company when making the calculation for reporting purposes. ..
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