Clinic Information
Clinic Name
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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District of Columbia
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New Hampshire
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic Phone Number
*
-
Area Code
Phone Number
Clinic E-mail
*
Do you currently offer healthcare coverage?
*
Yes
No
Clinic Current Health / Medical Carrier
Effective Date
*
please use mm/dd/yyyy
SIC Code:
0742
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AVMA Member Information
AVMA member information for each active member
Member Last Name
Member First Name
AVMA Member ID
AVMA Member
AVMA Member
AVMA Member
AVMA Member
AVMA Member
AVMA Member
AVMA Member
AVMA Member
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Employee & Dependent Information
Employees and Dependents to enroll in healthcare coverage
Last Name
First Name
Relationship Code
Gender
Date of Birth
Coverage Type
State Code
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
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Female
Employee Only
Employee and Spouse
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Employee and Family
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Employee
Spouse
Dependent
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Female
Employee Only
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Employee and Family
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Employee
Spouse
Dependent
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Female
Employee Only
Employee and Spouse
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Employee and Family
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Employee
Spouse
Dependent
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Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
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Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
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Employee and Family
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Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Enrollee
Employee
Spouse
Dependent
Male
Female
Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Submit
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