Thank you for your interest in in contracting to represent Health First plans. You will need to complete the following forms in the links below carefully to ensure contracting goes smoothly. Please make sure you write legibly so that your contract can be set up accurately.
- Broker Agreement – Please complete the highlighted fields on Page 8. Please indicate at the top if you are contracting for Medicare, Marketplace or both. Note you are completing all of the left hand side and only the email address and SS# on the right hand side. You will only complete the remaining fields if you are applying as an Agency instead of an agent. Be sure to check the “Agent” selection to get paid. Finally, be sure to sign and date the form. You only need to return Page 8.
- Business Associate Agreement – Please complete the highlighted fields on pages 1, 9 and 10. On Page 9, the “with a copy to” information is optional. Make sure you sign page 10. You only need to return pages 1, 9 and 10.
- W-9 – Request for Taxpayer Information – Complete the highlighted fields. In most cases you will only fill in the Social Security Number and not the Employer Identification number.
- FMO Alignment Form – in the middle of the form, complete name, email, NPN and Line of Business. Be sure to sign form and return with other documents.
- In addition to the above forms, we will need copies of the following:
- E&O – declaration page
- AHIP Certificate – current year
- Insurance License
- FFM Marketplace certificate (if contracting for the Marketplace)
- Return Instructions – If you can, please scan all the documents to us as one document (not individual documents). There will be 7 or 8 pages in your returned contracting document. Save the scanned document with the following naming convention – “HF- Your First and Last Name”. If you are unable to consolidate everything into one document, please send all the documents in one e-mail with “HF Contract – Your Name” in the subject heading.
- Send the scanned documents to firstname.lastname@example.org
Contracting will typically take 7-10 business days to process. You will receive an email directly from Health First when your contracting is complete with instructions on how to begin the certification process. Do not market any products until certification is complete. Again, thank you for your interest in representing Health First through the Plan Advisors Agency.