EXHIBIT B
EXAMPLE FORMS
TimelyCare Enrollee Verification Form:
Per the terms of the Agreement with TimelyCare, this represents the number of students eligible to utilize TimelyCare Services and is necessary for data reporting purposes.
Email
Your email ___
School Name ★
Your answer
Semester Count * Your answer
Name (Person Filling Out Form)
Your answer
Title Your answer
Billing Contact - Name
Your answer
Billing Contact - Email
Your answer ___
5