* Required field

Primary Holder Information

Please enter the following information:

*Holder Name:

*Holder Tax ID:

Holder ID:

*Contact Name:

*Contact Phone Number:

Phone Extension:

*Email Address:

*Email Address Confirmation:

Report Information

Please enter the following information:

*Are you submitting this report in response to an outreach letter received from the State?:

Yes

Reference ID:

*Report Type:

*Report Year:

*Total Dollar Amount Remitted:

Funds Remitted Via:

Does this report include records that are subject to the HIPAA Privacy Rule?:

Yes