Business Name (required)
Business Address (required)
Business Phone Number (required)
Business FAX (Optional)
Company Contact’s Email Address (required)
Would you like Roswell Urgent Care to submit your medical claims for you?No. Please send the claim to us and we will submit our own claims when needed.· Yes. Please submit our claims for us. Our Workers’ Compensation Carrier information is included below.· Yes. I would like you to submit our claims for us but I don’t have the insurance information right now.
Who is the contact person for your company? (required)