Tides Medical New Facility Information Form

Tides Medical New Facility Information Form
Please contact customerservice@tidesmedical.com or 888.494.4441 for any questions about this form.

Tides Medical is committed to providing excellent, timely customer service. Providing detail now will help us serve you best in the future.
Individual Completing Form: *

First Name Last Name
Individual Completing Form Email *
example@example.com
Sales Representative Name *

First Name Last Name
Agency Name
Are you a physician office or hospital/hospital affiliated wound clinic? *

Physician Office Hospital or Affiliated Wound Clinic
Group Purchasing Organization (GPO)
Integrated Delivery Network (IDN)
Facility Name *
Specialty *
Practitioner Name *

Title First Name Last Name
Main Contact *

First Name Last Name
Main Phone Number *

Area Code Phone Number
Main Email *
example@example.com
Main Fax Number

Area Code Phone Number
Person authorized to sign Customer Agreement
Signer Contact

First Name Last Name
Signer Email
example@example.com
Shipping Information
Shipping Attention Line
Shipping Address *

Street Address

Street Address Line 2

City State

Zip Code
Invoicing Information
Preferred Invoice Method *
Accounts Payable Contact Information

Same as main contact New
Accounts Payable Contact *

First Name Last Name
Accounts Payable Phone Number *

Area Code Phone Number
Accounts Payable Email Address *
example@example.com
Billing Address

Same as shipping New
Billing Attention Line
Billing Address *

Street Address

Street Address Line 2

City State

Zip Code
Purchasing Department Contact Information

Same as main contact New
Purchasing Contact

First Name Last Name
Purchasing Phone Number

Area Code Phone Number
Purchasing Email Address
example@example.com
Claims and Reimbursement Information

Tides is committed to providing timely and pertinent coding, coverage, and reimbursement information to your office. Including the following information will help us streamline that process.
Is biller off-site? *

Off-site biller On-site biller
Claims and Reimbursement Contact Name *

First Name Last Name
Claims and Reimbursement Email *
example@example.com
Claims and Reimbursement Phone Number *

Area Code Phone Number
Other Information
If State = X then, Territory = Y
By submitting this form you are agreeing to occasional, valuable updates about your Tides Medical products or reimbursement information related to Tides Medical products. Your privacy is very important to us and we do not share any information with 3rd party sites or affiliate companies. You have the option to opt-out at any time.
Should be Empty:

Tides Medical New Facility Information Form

Person authorized to sign Customer Agreement

Shipping Information

Invoicing Information

Claims and Reimbursement Information