HMA and RGA Virtual Behavioral Health Solution Sign-Up

This form is intended for HMA and RGA Virtual Behavioral Health Solution sign-up with Canopy EAP. If you found this form by mistake or need assistance with signing up a new group, please email salesteam@canopywell.com or call 800-433-2320.

HMA and RGA Group Sign-Up

Your Email Address

General Information

First Name

M.I.

Last Name

HMA / RGA Account Manager

First Name

Last Name

Address (Please be sure to include Street, City, State, and Zip)

Phone

Broker Information

Brokerage Company

First Name

Last Name

Address (Please be sure to include Street, City, State, and Zip)

Phone

Customer Information

DBA Company Name

Legal Company Name (If different from above)

First Name

Last Name

Title

Phone

Address (Please be sure to include Street, City, State, and Zip)

Industry Type

Preferred Start Date

EAP Services

Contact Canopy with questions about rates.

EAP Services

Option A (6x6) Option B (12x12)

Eligibility

Number of eligible employees on Medical Plan

Number of eligible employees NOT on Medical Plan ( If only medical plan members are covered, enter zero in this field.)

Accounts Payable

(for non-medical plan Members)

First Name

Last Name

Title

Phone