Online Registration Form

TO:
ATT:
FAX: 		TOPMED
WEB REGISTRATION TEAM
(031) 580 0461 (members)
(031) 580 0478 (employers)
(031) 580 0461 (providers)		    
To apply for your online access, please complete the relevant fields provided and then print, sign and fax this form to Topmed.
If you have any trouble filling in this form, an example with help, is available.
   
Applicants Name :
Company / Supplier :
Membership Number :
Practice Number :
Group Number :
Intermediary Number :
Contact / Cell Number :
Work Telephone Number :
Fax. Number :
Email Address :
Preferred User Name :
 
A User Name will be designated to you if the Preferred User Name field is left blank or the User Name has already been taken.

Group Members - Please ask you Human Resources or Finance manager to verify the application, sign it and mark with the company stamp.

Individual Members - Please be aware that if you're applying for individual member access you only need supply your membership number.

Once verified, we will allocate a password to use in conjunction with this User Name and email these details to the address
given above.

I accept that Topmed will not in any way be responsible or liable for any claims of any nature whatsoever made by anyone
(myself included) which arise as a result of my failing to keep my password and user name secure and confidential to myself.
I indemnify Topmed and hold it harmless against any such claims.

I understand that this service may not be available 24 hours a day.




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