HTA Client Forms
This online form is created for your convience. The information is securely faxed directly to our office.
You may also print out this PDF version to be printed out and faxed to our office.
Original invoices and/or receipts from payee/creditors "must" be faxed or emailed with this form All disbursements must be payable to a 3rd party Please allow 5‐7 business days to process request to completion.
ALL REQUESTS WILL BE ACKNOWLEDGED UPON RECEIPT – PLEASE CONTACT US IF WE DO NOT ACKNOWLEDGE RECEIPT OF YOUR REQUEST (510)749‐8358.