Change Request Form

If you are an existing customer and would like to make changes on your account please complete the following form. Complete this form to change address, account status, add / delete wearers, and / or correct the spelling of a badge wearer's name.

SECTION 1 - ACCOUNT INFORMATION
SERIES CODE RAD-BADGE: Required for ALL Requests! 7 character code found on back of badge.	SERIES CODE FOR TLD BADGE: Required for ALL Requests! 3 character code found on front of badge below bar code.
	ORGANIZATION / DEPARTMENT / DOCTOR NAME
CHANGE SHIPPING INFORMATION (All badges on this account will be shipped to this address via US Postal Service)
Contact / Administrator
Address
City
State
Zip Code
Phone
Fax
Email	e-mail is necessary to receive confirmation
Effective Date
	New Address
SECTION 2 - ACCOUNT CANCELLATION
	CANCEL MY ACCOUNT NOW Please return all badges at the end of their wear period.  You will be billed for an un-returned badge fee for all badges not returned within 15 days ($20 for each standard badge, $50 for each RAD-Badge). For standard badge cancellations to take effect they must be submitted 45 days prior to the next wear period.
We appreciate you let us know why are you cancelling service. At ICCARE we are committed to work with our customers.
SECTION 3 - ACCOUNT CHANGES Leave blank if no changes are required
UPGRADE - RADBG-G - 1 Year USB X-Ray Monitoring Service. Immediate dose report access from your computer, at your convenience, any time, no more shipping.
ADD - New badge wearer (you will be billed directly through your dental supply company) allow 15 business days to receive.
DELETE Badge wearerFor cancellations to take effect they must be submitted 60 days prior to next wear period.
CORRECT Information on existing badgeFor changes to take effect they must be submitted 60 days prior to the next badge mailing.
UPGRADE ADD DELETE CORRECT PARTICIPANT NUMBER (6 digit # - see front of TLD) PREFIX FIRST NAME INITIAL LAST NAME SUFFIX FETAL BADGE check here if changing to fetal
CORPORATE ACCOUNTS - If adding wearers to a corporate account please provide us with a purchase order #
SECTION 4 AUTHORIZATION REQUIRED As administrator, by submitting this form you hereby authorize the account changes above.