Altitude Census Request

Please use this form as a format to provide all of your employee's information. We understand you may have multiple employees. If you would prefer us, send you and editable spreadsheet; please make comment at the bottom of the form and we will email you the spreadsheet.

"*" indicates required fields

Do you want an editable spreadsheet emailed to you?*

Yes

Company Location Zip code

Location information will be ignored for Single-site groups.

Employee Details

Address

ZIP / Postal Code

Class Type

Name

First Last

Gender

Age

DOB

(MM/DD/YYYY)

Medicare Status

Annual Salary

Out of Area

OOA information will be ignored for Multi-site groups.

Employment Status

Spouse

Enter Age or DOB only if Spouse is being enrolled, if not, leave it blank.

Age

Enter Age or Date of Birth

Medicare Status