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Medicaid Provider Payment
Please fill out the form below to make a Medicaid Provider payment
Provider Name
*
Provider Physical Location Address
*
Address Line 1
Address Line 2
City
State
Postal / Zip Code
Use this as my billing address
SSN or FEIN
*
NPI Number
Payment Method
Credit Card
eCheck (
This may take up to 7 business days to process
)