CE Approved Provider Online Payment - NE MSD updated 12/21/17

Northeast Multistate Division

Approved Provider Applicant Payment

Please fill out the following form to pay for your Individual Activity Application online and by credit card. We accept VISA, MasterCard, Discover, American Express and PayPal.

*DO NOT HIT THE BACK BUTTON OR CLICK SUBMIT PAYMENT TWICE* This will cause a duplication of your payment. If you need a copy of your payment slip contact the billing department at professionaldev@ne-msd.org for assistance.

All approved providers are required to submit their application based on our cycles (March, July & November) Application not received on the date required will incur a $500 late fee. If you are unsure about the amount due please contact our office prior initiating payment.
Full Name*

First NameLast Name
E-mail*
Organization Name*
Primary Nurse Planner Name*
Date of Current Provider Expiration*
Preferred Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Options:
- Intent to Apply Fee $200.00
- New and Renewal Single Agency Provider $2,500.00
- New and Renewal System Provider $3,500.00
- New and Renewal Mega System Provider $4,800.00
- Provider Application Late Fee $500.00
- Provider Cycle Deferral Fee $ 250.00
- Incomplete Application Fee $ 250.00
- First Provisional Progress Report Fee $500.00
- Second Progress Report Fee $500.00
- Third Progress Report Fee $ 500.00
- Provider Application Consultation Fee [1 hour] $200.00
- Annual Reporting Fee - Single Agency $150.00
- Annual Reporting Fee - System Provider $250.00
- Annual Reporting Fee - Mega System Provider $400.00
Select a Payment Type- To see more payment options select credit card or check.*

Credit CardCheck
Intent-to-Apply Fee

$200.00
New and Renewal-Single Agency Provider [1 Facility]

$2,500.00
New and Renewal-System Provider [2-6 Facilities]

$3,500.00
New and Renewal-Mega System Provider [7 or More Facilities]

$4,800.00
Provider Application Late Fee

$500.00
Provider Cycle Deferral Fee

$250.00
Incomplete Application Fee

$250.00
First Provisional Status Progress Report Fee

$500.00
Second Progress Report Fee

$250.00
Third Progress Report Fee

$500.00
Provider Application Consultation Fee [1 hour]

$200.00
Annual Reporting Fee - Single Agency Provider

$150.00
Annual Reporting Fee - System Provider

$250.00
Annual Reporting Fee - Mega System Provider

$400.00
Total Amount Included
Check ID*
Please enter check ID. If check number is unknown please enter "unknown".
For the payment to be processed, you must follow the instructions below

Note: All check payments due in 30 days of dated of this payments slip, application submission and/or invoice. Overdue Invoices may incur a 5% interest charge.

1) Print your order confirmation page
2) Make check payable to Northeast Multistate Division
3) Attach your check with the this order confirmation page and mail to:

New Mailing Address!

Northeast Multistate Division
41 Second Street
North Andover, MA 01845
From Which Site*
prevnext( X )
Intent-to-Apply fee$200.00

New and Renewal-Single Agency Provider [1 Facility]$2,500.00

New and Renewal-System Provider [2-6 Facilities]$3,500.00

New and Renewal-Mega System Provider [7 or More Facilities]$4,800.00

Provider Application Late Fee $500.00

Provider Extension Fee$500.00

Provider Cycle Deferral Fee$250.00

Incomplete Application Fee$250.00

First Progress Report Fee$500.00

Second Progress Report Fee$250.00

Third Progress Report Fee$500.00

Provider Application Consultation Fee [1 hour]$200.00

Annual Reporting - Single Agency Provider Fee$150.00

Annual Reporting - System Agency Provider$250.00

Annual Reporting - Mega System Provider Fee $400.00

Provider Annual Report Late Fee$50.00

Total $0.00
Please check the options below that apply

**DO NOT HIT THE BACK BUTTON OR CLICK SUBMIT PAYMENT TWICE**

This will cause a duplication of your payment. If you need a copy of your payment slip please email the billing department at professionaldev@ne-msd.org, we will be more than happy to provide you with a copy.

Should be Empty: