Allied Care Solutions Wellness: New Client Implementation Form

Please complete this form for new Allied Care Solutions Wellness clients. If you have any questions, please call Kristen Balchan at 224.534.2278 (kbalchan@marqueehealth.com) or Jonathon Short at 224.534.2279 (jshort@marqueehealth.com).

 

This is the code that members will use to create their personal profile. It is typically the company name with no spaces. For example, the company code for ABC Manufacturing will be 'abcmanufacturing'.
Allied Care Solutions Wellness Plan Design *
Program Effective Date *
Program Effective Date
Key Contact at Allied *
Key Contact at Allied
Key Contact at Allied Phone Number
Key Contact at Allied Phone Number
Key Contact at Client
Key Contact at Client
Key Contact at Client Phone Number
Key Contact at Client Phone Number
If applicable, please type the broker name, email address and phone number here.