HealthiestYou - New Group Set Up Form - National Restaurant Association (NYSHTA) Header Image

new york state hospitality and Tourism Association

New Employer SetUp Form

Employer Information

HealthiestYou Complete Bundle (All Consults Included)

Effective Date (MUST be 1st of the month)*

Group Administrator Information

GROUP ADMINS: You can perform administrative functions for your group online with up to 2 people designated as administrators. Administrators have full access to add/change/terminate employees, view or modify non‐medical member data and view invoice status.

Admin 1 Name*

Admin 2 Name

Billing & Contract Information

Invoices will be generated on the first of each month and sent electronically to the group administrator(s) listed above unless a separate billing contact is listed below.

Is the billing contact the same as the group administrator?*
Billing Contact Name*
Is the contract signee contact the same as the billing administrator?*
Contract Signee Contact Name*

Eligibility Submission Method

Eligibility may be submitted via a one-time census spreadsheet file upload or can be manually entered into the Client Portal. 

When choosing Client Portal, credentials and instructions will be provided to the Group Administrator listed on page 1. 

When choosing One Time Census Spreadsheet (MFT), credentials and instructions will be provided to the Eligibility/IT Contact(s) provided in this section.

Additionally, certain eligibility may require an ongoing file transfer method (EDI feed). EDI feeds are typically established for groups with 50 employees or more that require frequent updates on a regular basis.

New groups that are submitted after the 1st of the month for the current month’s effective date must select and provide eligibility via One Time Census Spreadsheet (MFT) - (e.g. submitted on 12/5 for 12/1 effective date).

Method of Submitting Eligibility:*

Client Portal Eligibility Contact

Instructions for client portal manual entry will be sent to this contact

Eligibility Contact Name*

Primary IT/Eligibility Contact Information

Instructions for file transfer process will be sent to this contact

Eligibility Contact Name*

EDI Feed Contact Information

Instructions for EDI feed layout and transfer process will be sent to this contact

Eligibility Contact Name*

Broker/Consultant Information

For Brokers Only- If you are a broker, please complete the following information

Broker/Consultant Name

Account Manager Name

Submitter Information

A confirmation email of this form will be sent to this contact.

Submitter Name*