Group User Registration - Optimal teleHealth

Group Registration

Group Code*

A Group Code was generated when this account was initially set up in the MTM system. If that code is not accurately entered above, the interface to the MTM system will not work.
Essential Care ID*

The plan ID associated with the Group Code once entered into the MTM system.
Primary Care ID

The Rider plan ID associated with the Group Code once entered into the MTM system.
Company Name*
Tradenames For Benefit Preference Form
Is this a Multi-Unit Account?*
- Yes
- No
Select Mulit-Unit Account*
Allow Main Multi Unit Group Beneits Admistrator Access?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Association Name
Location Name
Location ID
Owner/Manager Name*
First Last
First and Last Name required.
Primary Contact Name*
Primary Contact Phone*
Email*
Username
Password
Hidden
Plain Password
Hidden
Affiliate ID
Type of Telemedicine Membership
Please indicate the type of memberships available to the client.
Telemedicine Coupon Code

Please enter a coupon code you would like to pass on to this group to adjust pricing.
Coupon Code 1: Group Essential Care Membership
Coupon Code 2: Group Primary Care Membership