Payer Application
Application Name:
Medical Day Health Services Fingerprint Archive Request
Individual Or Business Entity Information
Trade or Individual Name(If applicable):
Physical Address(Trade or Home):
Physical Address Line 2:
City:
State:
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
WASHINGTON DC
DELAWARE
FLORIDA
GEORGIA
GULF OF MEXICO
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
Zip:
Phone Number:
-
-
Fax:
Email Address:
Responsible Party Information
Last Name:
First Name:
Application Type Information
License/Permit/Certificate
Fingerprint archive request
Open Public Records Act (OPRA)
Alternative Treatment Center(ATC)
Other
Description:
New Registration
Renewal
Pertinent Number (may be required for some applications)
Number:
Expiration Date:(mm/dd/yyyy)
Fee Amount:
Payment Information
Select the type of service
Electronic Check Payment
Credit Card Payment
Note: E-check transactions will not incur any processing fees, whereas credit card transactions will be subject to a nominal processing fee.
Amount:
Security Message:
Not Case Sensitive
Enter Security Message: