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ASMBA

Forms

This area contains ASMBA's Medical Examination Form and Electronic Transfer Payment Authorization Form.  If a medical examination is required under the guidelines of the plan you are applying for, you may submit a copy of a recent (less than 12 months old) medical examination.  If you have not had an examination in the last 12 months, you may print ASMBA's medical exam form and take it to your physician to be completed.  Medical exams must be done at no cost to ASMBA.

For your convenience in setting up a bank draft, you may print, complete, and mail the Electronic Transfer Payment Authorization Form to: ASMBA, P.O. Box 160384, Nashville, TN 37216-9919. Forms may also be faxed to 615-851-9484. ASMBA forms cannot be completed and submitted on-line.

ASMBA Medical Exam Form

Electronic Transfer Payment Authorization

NOTE: Please allow at least one full month for your bank draft to begin. If you are not sure about the status of your account, please contact us as 1-800-251-8434 or e-mail us at accounting@asmba.com .

 

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