MW MSD Approved Provider Annual Fee Payment Form

Approved Provider

Activity File Documentation Review Fee
Organization Name*
Name of Approved Provider Unit (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:

Midwest MSD
3340 American Ave. Suite F
Jefferson City, MO 65109
* Activity File Review payments are due prior to reviewing the file(s) submitted.
value

Activity File Review Fee*

Activity File Review$200.00