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PROVIDER PAYMENT AUTHORIZATIONPO Box 1210 Atmore, AL 36504 Phone: (844) 9698777 Fax: (855) 6736710 www.fsatpa.comNAME: TRIBE: Tribal Roll Number:Email Address:Daytime Phone:Address of Primary Residence:.

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How to fill out the Fsatpa online

This guide provides a comprehensive overview of how to complete the Fsatpa form online. Follow the instructions carefully to ensure accurate and timely submission for payment authorization.

Follow the steps to successfully complete the Fsatpa form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Fill out your name in the designated field. This should be your full legal name as it appears on official documents.
  3. Indicate your tribe by selecting it from the provided options.
  4. Enter your tribal roll number in the appropriate section, ensuring it is accurate to prevent delays.
  5. Provide your email address clearly; this will be used for communication regarding your payment status.
  6. Fill in your daytime phone number for any necessary follow-ups.
  7. Complete the address of your primary residence, including street, city, state, and zip code.
  8. If your mailing address is different from your primary residence, fill in the details in the mailing address section.
  9. Select whether you are authorizing recurring payments or terminating payments. If you are authorizing payments, complete the service provider, expense/type of service, and billing address fields.
  10. Specify the due date and select the frequency of payments, either recurring monthly or one-time.
  11. Fill in the payment amount accurately in the designated field.
  12. Attach the required documentation, ensuring it includes the service provider's name, reference/account number, billing address for payment, and payment amount.
  13. Sign the form with your participant signature and date it. If applicable, include the signature of a tribal representative.
  14. Review the entire form for accuracy, then save changes. You can download, print, or share the completed form as necessary.

Complete your forms online today to ensure smooth processing of your payments.

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The FSA TPA Debit Card gives members a convenient method to pay for eligible expenses directly from their account. FSA TPA has the ability to create a card with specific merchant codes for only the benefits approved for the program. Cash withdrawals are not allowed with the FSA TPA Debit Card.

TRIBAL MEMBER BENEFIT PROGRAM Non-cosmetic medical, pharmacy, dental and vision expenses, such as copays, coinsurance, deductibles, etc. Expenses and benefits for the recently deceased will be covered up to six months post death.

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