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Get Credit Card Payment Form - Azdhs
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How to fill out the Credit Card Payment Form - Azdhs online
This guide provides clear and comprehensive instructions on how to effectively complete the Credit Card Payment Form for the Arizona Department of Health Services (ADHS) online. Whether you are renewing a license or making a payment, this step-by-step approach will assist you in filling out the form accurately.
Follow the steps to fill out the Credit Card Payment Form online:
- Click 'Get Form' button to obtain the form and open it in the editor.
- Fill in the licensee information section. Provide the name as it appears on the license, the ADHS License Number, and the Facility I.D. Number, if applicable. Enter the address listed on the license and the license expiration date.
- Indicate the applicable licensing office by checking only one option: Medical Facilities, Behavioral Health, Long Term Care, or Child Care.
- If this payment is for a renewal, confirm the total licensed or requested capacity if it applies, and answer if registered with the Empower Pack Program for child care facilities.
- Complete the record of transaction section by entering the order number, date of the transaction, the name of the person processing the transaction, their authorization number, and include their signature.
- In the credit card information section, select the type of credit card you are using (Visa or MasterCard). Enter the payment amount, name as it appears on the card, account number, expiration date, security code (three digits), and the cardholder's signature.
- Provide your mailing address, city, state, zip code, and daytime phone number.
- Finally, enter your email address and check that all fields are filled in clearly and accurately.
- After reviewing the form for any errors, you can save your changes, download, print, or share the completed form as needed.
Complete your Credit Card Payment Form online for a smoother process.
To take credit card payments as a contractor, begin by choosing a user-friendly payment processor. Tools like the Credit Card Payment Form - Azdhs make this process simple and secure. Ensure that the payment forms you use comply with industry standards for safety and customer ease.
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