Physician Office Staff

Enrollment

Physician Office Staff Request Type
New Enrollment Termination

Prefix

First Name

Middle Name

Last Name

Suffix

Last 4 SSN

Date of Birth (mm/dd/yyyy)

City Of Birth

Role

TGH Physician ID (optional)

Primary Email

Primary Phone Number

Physician Name
*

Practice Name

Street Address Line 1

Street Address Line 2

City

State

Zip

Are you a billing company or other individual not employed by the practice?
Company Name

* If your physician/provider/group is not listed, please contact TGH Help Desk at 813- 844-7490.