Fees (First month’s estimated Access Fee payment should be attached.)

 

AlliancePPO/MAPSI Products Number of EmployeesAccess Fee

Alliance PPO Network Only  ___________________  _________

MAPSI Network Only ___________________  _________

MAPSI Only (Includes Inpatient U.M.)  ___________________  _________

U.M. Only  ___________________  _________

Dental-Discount  ___________________ _________

Dental-PPO  ___________________  _________

MultiPlan  ___________________ _________

MAPSI Outpatient Pre-certification ___________________  _________

All Claims (PPO and Non-PPO) ___________________ _________

Other________________________ ___________________  _________

 

Alliance PPO/MAPSI Packages

Alliance PPO Network and U.M. ___________________ _________

Alliance PPO Network and MAPSI (Includes MAPSI U.M.) ___________________  _________

Alliance PPO and MAPSI Networks ONLY ___________________  _________  

Alliance PPO Network/U.M./MAPSI  ___________________ _________

Total Access Fees Per Employee Per Month _________