EOB Concierge Enrollment Form

Your employer may have chosen to enroll you in MaxMed105’s EOB CONCIERGE PROGRAM. Traditionally, a MaxMed105 member is required to send all insurance company’s Explanation of Benefits (EOB’s) to eba&m. With the EOB CONCIERGE PROGRAM this step will be done for you. To do this, eba&m will utilize the insurance company’s website to make a weekly sweep for each members’ EOB’s.

Access to the insurance company’s website is given to you, the member. To enroll in the EOB CONCIERGE PROGRAM, you will have to register online and then provide eba&m with your user name and password. DUE TO PRIVACY REGULATIONS, EACH MEMBER OF YOUR FAMILY OVER 16 YEARS OF AGE MUST CREATE THEIR OWN LOGIN.

To register, please go to your insurance company’s website. Follow their instructions to register as a user. After completing the registration, fill in your user name and password on this form. It is very important that you clearly indicate the correct user name and password, including upper and lower case letters.

Please keep in mind that it is your responsibility to provide us with your user name and password. If you fail to do so, or choose not to provide it to us, we cannot retrieve your EOB’s and it will be YOUR RESPONSIBILITY to send them in to eba&m! If for any reason your login information changes it is your responsibility to provide eba&m with the updated information. If your employer did not sign up for the EOB Concierge program, you must send in your EOB’s to eba&m Corporation for your claim to be processed.

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

I want to

EOB concierge enrollment form

Understand my EOB

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