Service Invoice Submission

Service Invoice Submission

for CDS Outside Vendors
Submission Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Please note: All submissions can take up to 45 days for processing. If you do not have updated forms 1739 & 1749 for the members new plan year please do not proceed and contact the FMSS department at 817-469-1977. Thank you
Vendor Name*
Vendor Email*
example@example.com
Vendor Phone Number*
Please enter a valid phone number.
Client Name*

First NameLast Name
Invoice Amount (in USD)*
Invoice*

Cancelof
Should be Empty: