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AccessOne MedCard New Cardholder Application

* Required Fields

Please enter your provider account number and select the facility where services were provided... Use the Add Another button, if you need to enter more than one account number. If you don't have an account number, but did receive services, then select the provider and enter the letter R (Reserved for Future Use) in the account number box.

Account Number * *

First Name *
Middle Name
Last Name*
Email Address
SSN
Check if you have no SSN
Date of Birth (MM/DD/YYYY) *
Address Line 1 *
Address Line 2
City *
State *
Zip *

You must enter at least one phone number*

Home Phone (###)###-####
Work Phone (###)###-####
Mobile Phone (###)###-####

Check if you speak Spanish
Check if you have insurance

Other authorized user:

First Name
Last Name
Relation (spouse, father)

*
CORRESPONDENCE: PAYMENTS:
AccessOne MedCard, INC AccessOne MedCard, INC
PO Box 410806 DEPT #0763
Charlotte, NC 28241-0806 PO Box 2252
  Birmingham, AL 35246-0763