MW MSD Approved Provider Annual Fee Payment Form

Approved Provider Activity File Documentation Review Fee

Payment Form
Organization Name*
Name of Approved Provider (if different)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

First NameLast Name
Contact Title*
Preferred Phone*

Area CodePhone Number
Preferred Email*
Educational Activity Title and Date Provided:
Example: ABCs of Event Planning; provided 12/12/19
Select a payment type*

Credit CardCheck
Activity File Review Fee*

$200.00
Please make checks payable to:

VTL Solutions
217 Oscar Drive, Suite C
Jefferson City, MO 65101
* Activity File Review payments are due prior to reviewing the file(s) submitted.
value

Activity File Review Fee*

Activity File Review$200.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Approved Provider Activity File Documentation Review Fee