EOB Concierge Enrollment Form

Your employer has enrolled you in the EOB HRA Concierge Program. Traditionally, EOB HRA members needed to submit all Explanation of Benefits (EOBs) from their insurance provider to EBA&M. With the EOB HRA Concierge Program, this step is handled for you. EBA&M will conduct a weekly sweep on the insurance provider’s website to securely retrieve each member’s EOBs, ensuring a seamless and efficient process.

Access to the insurance company’s website is provided to you, the member. To enroll in the EOB HRA Concierge Program, please register online with your insurance provider and then share your username and password with EBA&M. Due to privacy regulations, each family member over 16 years of age must create their own login.

How to Register:

Go to your insurance provider’s website and follow their instructions to create a user account.
After completing registration, provide your username and password to EBA&M on this form, being mindful to enter them accurately, including any capital or lowercase letters.

Please remember, it is your responsibility to share your login credentials with us. If you choose not to, or fail to provide them, EBA&M will not be able to retrieve your EOBs, and you will need to send them to EBA&M yourself. If your login details change at any time, please provide EBA&M with the updated information.

If your employer has not opted into the EOB Concierge Program, you will need to submit your EOBs directly to EBA&M for claim processing.

EOB Concierge Enrollment Form

You must submit a separate form for each member over 16 years of age.

IMPORTANT: You must enter the username, password, and other information you use to log in to your medical insurance carrier’s website. Do not make up new login information below.

Member Name*
Employer Name*
Member Email*
User Name*
Insurance Carrier*
Password:*
Security Question 1 (leave blank if not applicable)
Answer 1
Security Question 2 (leave blank if not applicable)
Answer 2
Security Question 3 (leave blank if not applicable)
Answer 3
Allow EBA&M to make changes to your account
- Allow EBA&M to make changes as required by your medical insurance carrier
Allow changes to your password, security questions and answers, and other login information as required by your medical insurance carrier. If changes are made, we will notify you of those changes so you can maintain access to your account. If you choose to opt out of allowing EBA&M to make future changes to your login information, you acknowledge that when your insurance carrier’s login requirements change, we will lose access to your account until you re-submit your updated credentials here.
Consent*
I understand
I understand that submitting this form is not a guarantee of coverage. I understand that enrollment in the EOB CONCIERGE PROGRAM is voluntary and I can cancel my participation at any time. By clicking the "Enroll" button below, I authorize eba&m to receive protected health information about me in order to assist me in the filing of my MaxMed105 claims.
Email
This field is for validation purposes and should be left unchanged.

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EOB concierge enrollment form

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