TelaMed Plus Admin TMP Site

Welcome to the TelaMed Plus Adminstrative Changes Page
This page is for adding, terminating or making changes to your group's membership.
I would Like to:*

Add a new memberTerminate an existing memberMake changes to an existing member
Effective Date:*

MonthDayYear
Please enter the new or existing member's information below:
Name of your group or Group Billing Number:*
Full Name*

First NameLast Name
Member I.D. Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender:

MaleFemale
Date of Birth:

MonthDayYear
E-mail
I have read and accept:

By selecting the "I have read and accept" checkbox, you are agreeing to terms and conditions of your group's list bill agreement and general terms and conditions of your group's benefits with TelaMed Plus on behalf the employee listed above.
Person Completing Form:

First NameLast Name
Should be Empty: