Texas True Choice
New Group Implementation Form
If you wish to mail or fax your completed form,
our
PDF version
is available for printing. Otherwise,
please complete and submit the following online
form to notify us of a new group.
(
download the free Adobe Acrobat Reader now
)
EMPLOYER GROUP INFORMATION
Effective Date:
Group#:
Employer Name:
DBA/Other Name by Which Company is Known:
Address:
City:
State:
Zip Code:
Contact:
Title:
Phone#:
Fax#:
Total Employees:
Broker Name/Phone:
TPA/CLAIMS PAYOR INFORMATION
TPA Name:
Fax#:
Street Address:
City:
State:
Zip Code:
Account Manager:
Phone#:
Claims Contact:
Phone#:
Billing Contact:
Phone#:
Customer Service/Coverage/Eligibility Phone#:
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