Please complete the form below to notify CuraLinc Healthcare of a new American Fidelity client. Your CuraLinc Client Relationship Manager will send a confirmation of receipt within two business days.

Program Effective Date *
Program Effective Date
Client Contact Address
Client Contact Address
Client Contact Name
Client Contact Name
Client Contact Phone Number
Client Contact Phone Number
American Fidelity Contact Name *
American Fidelity Contact Name
American Fidelity Contact Phone Number
American Fidelity Contact Phone Number
(if applicable)
Client Broker Phone Number
Client Broker Phone Number
Billing
Client Billing Information
Client Billing Information
Client Billing Address
Client Billing Address
Client Billing Phone Number
Client Billing Phone Number
(if applicable)
Is Company an American Fidelity Portfolio client?
Does the company have a UR vendor? If so, who is the provider?
Does Company have a Disease Management vendor? If yes, who is the vendor?
Does Company administer a Health Risk Assessment Test? If yes, who is the provider?
Does the company provide mental health and substance abuse (MHSA) benefits? If so, what is the company's MHSA network(s)?

Note: In addition to short-term counseling, all American Fidelity models include free legal and financial consultation, expert dependent care referrals, organizational consultation, video counseling and a technology suite (web platform and mobile app) that can be tailored at a group, client or partner level. All programs also include access to worksite service components, such as critical incident response services and training.