New Client - USI - Marquee Health

USI Wellness Form

We are delighted to have you on board as our valued new client. To ensure we provide you with the best possible service and cater to your unique needs, we kindly request you to complete our New Client Form.

USI Wellness Form

Client Name(Required)

Number of Covered Employees(Required)

Eligible Population

Billed based on ee count

If Other Eligible Population Enter Here

Plan Design

Select all that apply to your program

Foundational (PCP Form — Signature only)

Essential (PCP Form with Biometric Data)

Advanced (PCP Form with Biometric Data + Age/Gender Screening Tracking)

Program Effective Date

Key Contact at USI

Key Contact at USI Phone Number

Key Contact at USI Email Address

Key Contact at Client

Key Contact at Client Phone Number

Key Contact at Client Email Address

Client Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Services/Information (if applicable)

Name

This field is for validation purposes and should be left unchanged.