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?*

YesNo
Mailing Address (if not the same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company Phone Number*
Fax Number*
Number of Employees*
SECTION II: CONTACT PERSON
Primary Contact Name*

First NameLast Name
Primary Contact Title*
Primary Contact Phone*
Primary Contact Fax*
Primary Contact E-mail*
example@example.com
SECTION III: BILLING CONTACT
Is the Billing Contact the Same as the Primary Contact?*

YesNo
Billing Contact Name (if different from primary contact)

First NameLast Name
Billing Contact Title
Billing Contact Phone
Billing Contact E-mail
example@example.com
SECTION IV: BILLING PREFERENCES
How Would You Prefer to Receive Invoices?*

MailEmailFax
What is Your Preferred Billing/Payment Method?*

Balance Billing (monthly invoice of open charges)Credit Card (requires credit card on file)
SECTION V: OUR SERVICES
Which Services Would Benefit Your Company (check all that apply)?*

DOT Drug/Alcohol TestingNon-DOT Drug/Alcohol TestingBreath Alcohol TestHair CollectionDOT Physical ExamsSchool PhysicalsPre-employment PhysicalsReturn To Work PhysicalsLab TestsCOVID TestingCOVID VaccinationsFlu ShotsTB Skin TestVision Testing
SECTION VI: DRUG-FREE WORKPLACE POLICY
Does Your Company Have a Drug Free Workplace Policy?*

YesNo
Enter the message as it's shown*
Should be Empty:

SECTION I: COMPANY INFORMATION

SECTION II: CONTACT PERSON

SECTION III: BILLING CONTACT

SECTION IV: BILLING PREFERENCES

SECTION V: OUR SERVICES

SECTION VI: DRUG-FREE WORKPLACE POLICY