Worship Health Corporate Onboarding Form

1
To begin the onboarding process, here are a few important guidelines:

Please ensure the provided information is accurate. Any discrepancies might lead to delays in the onboarding process.

After reviewing your form submission our team will contact you to initiate next steps in the onboarding process.

If you have any questions or require assistance completing this form, please contact support@worshiphealth.org
2
Organization Name* This field is required.
3
Organization Type* This field is required.
Non-profit / Affiliate Organization
Employer Organization
4
Organization Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Expected Program Start Date
Date
Month
Day
Year
6
Administrative ContactThis individual will serve as the primary Organization Administrator for the OptimalMD portal. Their responsibilities and system access include billing summary review and payment, onboarding new employees, and managing terminations within the OptimalMD platform.
First Name
Last Name
7
Administrative Contact Direct Phone NumberThis individual will serve as the primary Organization Administrator for the OptimalMD portal. Their responsibilities and system access include billing summary review and payment, onboarding new employees, and managing terminations within the OptimalMD platform.
Please enter a valid phone number.
8
Administrative Contact Email AddressThis individual will serve as the primary Organization Administrator for the OptimalMD portal. Their responsibilities and system access include billing summary review and payment, onboarding new employees, and managing terminations within the OptimalMD platform.
example@example.com
9
Billing Contact(if different from Administrative Contact) This person will complete a separate form providing payment details for automatic ACH or credit/debit invoice payments.
First Name
Last Name
10
Billing Contact Phone Number(if different from Administrative Contact) This person will complete a separate form providing payment details for automatic ACH or credit/debit invoice payments.
Please enter a valid phone number.
11
Billing Contact Email Address(if different from Administrative Contact) This person will complete a separate form providing payment details for automatic ACH or credit/debit invoice payments.
example@example.com
12
DOWNLOAD MEMBER FILE

Please download the Excel template here and complete it per the instructions provided. Once filled out, please upload the completed file in the next section.
13
UPLOAD MEMBER FILE Please upload the completed excel file containing a list of your employees here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
ALMOST DONE!

Final Steps to Activation:

Great news! Once we receive your filled-out onboarding form, our team will swiftly create an initial invoice for your primary members. After the invoice is settled, your members will be sent emails with links for them to register themselves and their dependents in the OptimalMD portal.

This is the final step to start enjoying their Telehealth and pharmacy benefits.

We're thrilled to welcome you aboard!
15
ALMOST THERE!

How to Add New Members:
Upon receiving your completed form, we'll quickly set up your organization in our portal. You'll then receive a welcome email with a link and a custom referral code to share with your members. This referral code will allow all your members and their families to self-register on the OptimalMD portal and start accessing their healthcare benefits. We're thrilled to support your mission!
Should be Empty: