Texas Med Clinic New Account Set-Up Form Page 2
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Account Number:
2
New Account Set-Up Form | BILLING
Fax: 210.471.0217 | email:
Company Name:
Physical Address:
City:
State:
Zip Code:
Phone:
Fax:
My Company has multiple locations
Billing Information for Occupational Services:
The billing address same as above
Name of TPA (if applicable):
Billing Address (
if different than physical address):
City:
State:
Zip Code:
Phone :
Fax:
Billing Information for Workers’ Compensation:
Subscriber
Name of Workers’ Comp Insurance:
If your are in a Network, please indicate which one:
Non Subscriber
(Do not have workers comp insurance)
Billing Address if different than Physical address above:
City:
State:
Zip Code:
Phone :
Fax :
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Parent category: Medical