Online Group Enrollment

AllyHealth provides your employees all these benefits!

Each Subscription Covers Your Employee and Their Dependents

AllyHealth members get discounts on out-of-pocket prescription drug purchases, medical bill negotiation services, and access to AllyHealth’s telemedicine service without having to pay a consultation fee.

Rx Savings

Medical Bill Negotiation

Telemedicine

Only $8/Month Per Employee with no consultation fees

SPEAK TO A DOCTOR ANYTIME, ANYWHERE

AllyHealth Online Group Enrollment

Step 1 of 4

Welcome! This page allows you to sign up your company or group for AllyHealth telemedicine electronically. Simply complete the form below, upload your member census, and then submit. A member of the AllyHealth enrollment team will then contact you to confirm your information and guide you through the rest of the onboarding process. We look forward to working with you and we hope your team really enjoys our service!

Need help using this page? Don't hesitate to call AllyHealth at 215.543.7400 or email us at enrollment@allyhealth.net
Provide Group Billing Information
Business/Group Name:*
EIN / Tax ID #*
Business Billing Address*
Street Address City State ZIP Code
Group Administrator Name*
First Last
Title*
Email*
Phone*
# of Members Enrolling*
Desired Effective Date*
MM slash DD slash YYYY

*Effective Date should be on the 1st of the month. Special exemptions can be made at client's request.

Confirm Products and Pricing
Desired Plan:*
- AllyHealth Telemedicine Group Plan ($8 PEPM)
Ship New Member Letters to:*
- Members' Personal Address
- Group Administrator
Select Payment Method
Payment Method*
- Check with Monthly Invoice
- Credit Card
- ACH / AutoDraft
Name of Account Holder*
Bank Name*
Bank Account Number*
Bank Account Routing Number*
Bank Address*
Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Upload Member Information (Census)
First, Please Download AllyHealth's Member Census Template File with the link below:
Census Spreadsheet Template
Upload Member Census File*
Max. file size: 50 MB.
After filling out the Excel Census Template with your members' information, upload the excel or CSV formatted file here.

Review Group Enrollment Terms
You hereby authorize AllyHealth to charge you by the above-referenced payment method. You also hereby authorize AllyHealth, its agents, affiliates, and vendors, to offer our services to your eligible employees/members subject to the following terms and conditions:
1. You agree to provide us with census data if needed for us to determine proper enrollment eligibility.
2. For voluntary enrollments, you agree to provide a suitable location on your property during normal business hours, or through other means mutually agreed upon between you and us. Participation in your group must meet our minimum participation requirements. We reserve the right to withdraw from the enrollment and cancel any applications already obtained if these conditions are not satisfied.
3. We customarily bill you around the 1st of each month for services to be provided in that month. You agree to forward the membership fees due to us by the 25th of each month for the month in which you are billed.
4. This Agreement is subject to the Group Terms and Conditions, which are available for download and print from the following location: "www.allyhealth.net/group-terms-conditions/
I agree that no member services will be effective until approved by us at our administrative office.
Sign for Approval
Signature
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

AllyHealth provides your employees all these benefits!

Each Subscription Covers Your Employee and Their Dependents

AllyHealth Online Group Enrollment

Step 1 of 4

Provide Group Billing Information

Confirm Products and Pricing

Select Payment Method

Upload Member Information (Census)

Review Group Enrollment Terms

Sign for Approval

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