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Request a Card

  1. If you have lost your card, please complete the following information to request a new card be issued to you.

  2. Is this card for*

    Please select one

  3. You can have up to three additional cardholders apart from the primary

  4. Please provide any further instructions or questions you may have here

  5. Please allow 7 to 10 days to receive your new card. If the card is not received in this time period, please give us a call at 325-795-4200.

  6. Once your card is received, activate immediately and record your attendance for the previous six (6) days. If you fail to record attendance, provider has the right to refuse care.

  7. Note: Once request is made, previous card will no longer be active.

  8. Leave This Blank:

  9. This field is not part of the form submission.