New Employer Account Set Up

2316 E. Joppa Rd., 2nd Floor

Parkville, MD 21234

Ph: (443) 793-7220 | F: (443) 687-8705
NEW EMPLOYER ACCOUNT SET-UP FORM

Please fill in the information below to set up an employer account with True Phoenix Community Care.
SECTION I: COMPANY INFORMATION
Company Name
Company EIN Number
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
Is the Mailing Address the Same as the Physical Address?
Mailing Address (if not the same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Number of Employees
SECTION II: CONTACT PERSON
Primary Contact Name

First NameLast Name
Primary Contact Title
Primary Contact Phone
Format: (000) 000-0000.
Primary Contact Fax
Format: (000) 000-0000.
Primary Contact E-mail
example@example.com
SECTION III: BILLING CONTACT
Is the Billing Contact the Same as the Primary Contact?
Billing Contact Name (if different from primary contact)

First NameLast Name
Billing Contact Title
Billing Contact Phone
Format: (000) 000-0000.
Billing Contact E-mail
example@example.com
SECTION IV: BILLING PREFERENCES
How Would You Prefer to Receive Invoices?
What is Your Preferred Billing/Payment Method?
SECTION V: OUR SERVICES
Which Services Would Benefit Your Company (check all that apply)?
SECTION VI: DRUG-FREE WORKPLACE POLICY
Does Your Company Have a Drug Free Workplace Policy?
Enter the message as it's shown
Should be Empty:

SECTION I: COMPANY INFORMATION