PROVIDER LOOKUP REQUEST Provider Lookup Request Step 1 of 4 25% Name(Required) First Last Phone:(Required)Email Provider List(Required)Please list care providers you wish to continue services with. To add more providers, click the + icon at the end (on the right) of the previous provider entry.Provider First NameProvider Last NameDr. Type, if known (MD, DO, DDS, etc.)Group Affiliation, if known (Everett Clinic, MultiCare, etc.) Add Remove Additional Providers/Questions/Comments/NotesPlease provide us with any other information that may help, otherwise click the NEXT button below. Consent(Required)By checking this box, you allow us to contact you regarding our services and products. Any information provided will be used for internal use only. I understand that Benefit Solutions Plus, LLC is bound under regulations to keep all personal information private, and will not sell personal information to any third party company. I agreeCAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
