Primary Care Telehealth And EAP Benefit Enrollment Form
Please complete this form to request enrollment in Apricott ABA’s Telehealth benefits. Select the program(s) you wish to enroll in and provide the necessary details to ensure a smooth enrollment process.
Name
First Name
Last Name
Job Title
Personal Email
example@example.com
Phone Number
Please enter a valid phone number.
Program Selection:
Please select the program(s) you would like to enroll in:
Primary Care Telehealth (Doctegrity)
Employee Assistance Program (EAP) - 24/7/365 access to licensed mental and behavioral health counselors and therapists
Both Programs
DOB:
-
Month
-
Day
Year
Date Of Birth
Your Zip Code:
Acknowledgements:
I understand that my enrollment in the selected program(s) begins on the 1st of the month following the submission of this form. (The form must be completed by the 25th of the month for the benefit to take effect the following month.)
I acknowledge that to maintain access, I must confirm my enrollment twice per year during the designated confirmation periods: June 15 –June 25 and December 15 – December 25. Failure to confirm during these periods will result in loss of access to the benefits.
I confirm that I have read and agree to the terms of the selected benefit(s).
Signature
Continue
Should be Empty: