Please Note:

• The full contract is included through the contract link and can be printed out, but only the following pages have fillable fields: 1-3, 14, 24-26, 28.
• The contract must be completed in 1 sitting and takes approximately 10 minutes.
• You can navigate through the pages using the UP and DOWN arrows or the Page X of 31 box on the bottom of the screen.
• Only the fields in green and yellow can be completed. The fields in green are required. Please make sure to provide this information.
• When you get to a signature field, use your mouse to sign the document and then click on the green check mark to accept it.
• When you are finished filling out the document, please click the complete button on the top right of the screen. If you are missing any required fields, it will prompt you to complete that information prior to submitting.

If you’d like assistance completing the contract, click here to schedule a phone appointment.
Important- In order to process your contract we MUST receive the following:

• Currently Active Michigan State License
• Current E&O Certificate
• 2017 Medicare Training Certificate (AHIP)
• Fraud, Waste, and Abuse Training Certificate

Please submit ASAP
Email: [email protected]
FAX: (480)-376-8670
Contact RBI’s Onboarding Department at 1-800-997-3107 if you have any questions or issues with completing this contract.

 

Harbor Health Plan is positioned to be the Top Plan in the Detroit Metro Area for 2017.

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