Payer Application
 Application Name: Ambulatory Care Facility - Initial Registration
 Individual Or Business Entity Information
Trade or Individual Name(If applicable):
Physical Address(Trade or Home):
 Physical Address Line 2:
City:
State:
Zip:
Phone Number:
- -
Fax:
Email Address:
 Responsible Party Information
Last Name:
First Name:
 Application Type Information
 Payment Information
  Select the type of service        Electronic Check Payment        Credit Card Payment
 Amount: