- THIS PAYMENT FORM IS TO BE USED ONLY FOR TRAVELERS ON THE OUTBOUND CHARTER FLIGHT.
- You may also have a representative make a payment on your behalf at the Accounts Payable Office at the Executive Office Building in Utulei. Please pick up a Medicaid Payment Form from the Medicaid Tafuna Office before making the payment.
Refunds may take up to 30 days to process.
$800.00 USD plus a $20 dollar fee for online payments = TOTAL $820.00