If you would like to make changes to an account with Health Management
Systems, Corp. please fill out the following form.
USE THE TAB OR MOUSE, NOT THE ENTER,
TO MOVE BETWEEN FIELDS. The enter key will submit the form. If
you hit the enter key prior to completion of the form, use your back button and
continue filling out the form. Click submit or Enter when done.
Account #:
*****Enter only the information that needs to be changed
or updated*****
Billing Information:
Company Name:
A/P Contact Name:
Address:
City: State:
Zip:
Phone:
Fax:
Email:
Shipping Information:
If same as billing
check here
and
move to next section.
Company Name:
Receiving Contact Name:
Address:
City: State:
Zip:
Phone:
Fax:
Email:
Other Information:
Purchasing Contact:
Name:
Phone:
Email:
Tax Exempt: Yes
No (if yes,
please fax tax exempt certificate to (972) 578-9854)
Legal Structure: Corporation
LLC
LLP
Partnership
Sole Proprietor
Non-Profit
