Recuro COMPLETE Care Master Application

Recuro Health COMPLETE Care Group Application

Please fill out completely to set up your account for Telehealth and Employee Assistance, At home Labs, Genome testing and Virtual Primary Care!
Your Agent's name (NOT YOUR NAME)*
Please type the name of your agent. (Not Voluntary Insurance Partners, LLC)
Your Agent's email address (NOT YOUR EMAIL)*
(first initial, last name)@voluntarypartners.com

Today's Date*

MonthDayYear
Date
Your Company/Group Name:*
ABC Plumbing LLC
Group's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Is the mailing address the same as above?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Number of eligible members? *
Select the effective date of coverage:*
All effective dates must be the first of the month. Billing is a month in arrears through Bill.com
Group Contact Name:*
Group Contact Title:*
Group Contact Email*
example@example.com
Group Contact Phone Number:*

Area CodePhone Number
Are you the billing contact?*

YesNo
Billing Contact Name:*
Billing Contact Title:*
Billing Contact Email*
example@example.com
Billing Contact Phone Number:*

Area CodePhone Number
Are you the contact for managing employee eligibility for your company?*

YesNo
Eligibility Admin Contact Name:*
Eligibility Contact Title:*
Eligibility Contact Email*
example@example.com
Eligibility Contact Phone Number:*

Area CodePhone Number

ACH Payment Information

ACH is required for RECURO Health. Please complete the rest to have hassle free invoicing and billing!
Schedule your payment to be automatically deducted from your checking or savings account by completingthe below form! Upon receipt of completed form and voided check, we will complete the setup!

Recurring Payments Will Make Your Life Easier:

• It’s convenient (saving time and postage)

• Your payment is always on time, eliminating late charge or cancellation of services

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking or savings account. You will be charged the amount invoiced on the 1st of the month. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an "ACH Debit". You agree that no prior notification will be provided prior to the payment being processed.

YOU WILL NEED TO UPLOAD A VOIDED CHECK or ACCOUNT VERIFICATION LETTER FROM YOUR BANK.
Do you want to set up ACH?*

YesNo
Type of Account:*

CheckingSavings
Name on Account:*
Bank Name*
Bank City and State*
Account Number*
Routing Number*
YOU WILL NEED TO UPLOAD A VOIDED CHECK or ACCOUNT VERIFICATION LETTER FROM YOUR BANK HERE.

Browse Files

Cancelof
The Employer hereby agrees and understands that access to the services and Programs provided by Recuro Health is based on the information provided in this Application and Agreement, which Employer hereby represents is true and accurate, and that acceptance of these services by the Employer constitutes agreement to all terms and conditions of the Application, the Agreement and the Recuro Health Terms and Conditions attached hereto and made part of this Agreement.

By the FIFTEENTH (15th) calendar day of each month of the Term Recuro Health shall deliver to the Employer an invoice for the Recuro Health services to be rendered in that month calculated in accordance with Recuro Health Terms and Conditions. Recuro Health shall invoice Client for the Access Services based on the number of Client’s employees included on the Client Eligibility File as of the last business day of the previous month, which invoice shall be conclusive evidence of the amount owed by Employer to Recuro Health.

By completing and executing this Agreement, the undersigned Employer agrees to the conditions printed above and the Recuro Health Terms and Conditions attached hereto and made part of this Agreement. In witness whereof, the parteis hereto have executed this Agreement on the day and year first above written.
Signature*

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