CuraLinc | New Client

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

Client Name

Program Effective Date

YYYY

Number of Employees

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Contact Name

First Name

Last Name

Client Contact Phone Number

(###)

###

####

Client Contact Email Address

AmeraPlan Contact Name

First Name

Last Name

AmeraPlan Contact Phone Number

(###)

###

####

AmeraPlan Contact Email Address

Broker Company

(if applicable)

Broker Contact Name

Broker Email

Plan Design (Session Model)

3-Session

5-Session

8-Session

SupportLinc Website Username

Utilization Review (UR) Vendor

Does the company have a UR vendor? If so, who is the provider?

Disease Management

Does the company have a disease management vendor? If so, who is the vendor?

Health Risk Assessment

Does the company administer a health risk assessment test? If so, who is the provider?

MHSA Network

Does the company provide mental health and substance abuse (MHSA) benefits? If so, what is the company's MHSA network(s)?

Additional Information

Note: In addition to short-term counseling, all AmeraPlan 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.

AmeraPlan

New Client Implementation Form