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Contact Us By Phone (404) 289-7888 By Fax (678) 904-0903 By E-Mail tbm1ins@aol.com By Mail Total Billing Management 3951 Snapfinger Pkwy Ste 400 Decatur, GA 30035 On-Line: Complete the form below and click the 'Submit' button. * (asterisk) means required information First Name *   Last Name *   Company or Practice Name *   Specialty * -- Select -- Behavioral Therapy Clinical Nurse Specialists LMFT LMHC Neuoropsychologists Chiropractic Psychologists MSW LCSW Psychiatrists Psychiatry   Number of Providers * -- Select -- 1 2 3 4 5 6 7 8 9 10      Address 1 *   Address 2 City *   State * --Select a State-- AE   US Military AK   Alaska AL   Alabama AR   Arkansas AZ   Arizona CA   California CO   Colorado CT   Connecticut DC   District Of Columbia DE   Delaware FL   Florida GA   Georgia HI   Hawaii IA   Iowa ID   Idaho IL   Illinois IN   Indiana KS   Kansas KY   Kentucky LA   Louisiana MA   Massachusetts MD   Maryland ME   Maine MI   Michigan MN   Minnesota MO   Missouri MS   Mississippi MT   Montana NC   North Carolina ND   North Dakota NE   Nebraska NH   New Hampshire NJ   New Jersey NM   New Mexico NV   Nevada NY   New York OH   Ohio OK   Oklahoma OR   Oregon PA   Pennsylvania RI   Rhode Island SC   South Carolina SD   South Dakota TN   Tennesee TX   Texas UT   Utah VA   Virginia VT   Vermont WA   Washington WI   Wisconsin WV   West Virginia WY   Wyoming AB   Alberta BC   British Columbia MB   Manitoba NB   New Brunswick NL   Newfoundland and Labrador NS   Nova Scotia NT   Northwest Territories NU   Nunavit ON   Ontario PE   Prince Edward Island QC   Quebec SK   Saskatchewan VI   US Virgin Islands YT   Yukon   Zip/Postal Code *   Phone Number *   Alternate Phone Number Email Address *   Confirm Email Address *   Comments or Questions

Total Billing Management 3951 Snapfinger Parkway, Suite 400 Decatur, Georgia 30035 Phone: (404) 289-7888    Fax: (678) 904-0903

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