• Agencies

OHSD PHV BK Form

Description: For payment of the Ohio Southern District Bankruptcy Court pro hac vice fee.
Form Number: OHSD BK PHV

FDIC Payment Form

Description: Complete this form to pay a miscellaneous payment to the FDIC using a credit card or ACH debit.
Form Number: FDIC 4531 13 6-06

ILNB Online Payment Form

Description: Use this form to pay filing fees and installment payments for Ch. 7/11/12/13, filing fees for all other documents, record searches, copies, certifications, and exemplifications for the U.S. Bankruptcy Court, Northern District of Illinois. If you are filing a new case, enter '99-99999' in the case number field.
Form Number: ILNB Payment

Bayne-Jones Army Community Hospital (0064)

Description: Please use this link to pay medical bills.
Form Number: DHA Bayne Jones ACH 0064

Beaufort Naval Hospital (0104)

Description: Please use this link to pay medical bills.
Form Number: DHA BEAUFORT NH (0104)

Bremerton Naval Hospital (0126)

Description: Please use this link to pay medical bills.
Form Number: DHA Bremerton NH (0126)

BSEE Application for Permit to Drill (APD)

Description: Use this form to pay for your OCS Application for Permit to Drill (APD) (MMS-123, MMS-123S) for mailed or faxed applications only. Please use the BSEE eWell interactive payment link to pay for electronic applications submitted through eWell.
Form Number: 12412342342

BSEE Application for Permit to Modify

Description: Use this form to pay for your OCS Application for Permit to Modify (APM) -MMS-124- for mailed or faxed applications only. Please use the BSEE eWell payment link to pay for electronic applications submitted through eWell.
Form Number: MMS-124
OMB Number: 1010-0141

Camp Pendleton Naval Hospital (0024)

Description: Please use this link to pay medical bills.
Form Number: DHA Camp Pendleton NH (0024)

CMS Data Payment Form

Description: Please use this form to pay for fees related to accessing public use files, limited data sets, and research identifiable files. Also use this form to pay all other recovery of data processing fees from the Centers for Medicare & Medicaid Services. This form is NOT to be used for submitting the CMS 855 Application Fee. If you need to submit a new enrollment or revalidation fee, please use the following link:
Form Number: CMS Data Payment

Guam Naval Hospital (0620)

Description: Please use this link to pay medical bills.
Form Number: DHA Guam NH (0620)

Guantanamo Bay Naval Hospital (0615)

Description: Please use this link to pay medical bills.
Form Number: DHA Guantanamo Bay NH (0615)

Hawaii Naval Health Clinic (0280)

Description: Please use this link to pay medical bills.
Form Number: DHA HAWAII NHC (0620)

Lemoore Naval Health Clinic (0028)

Description: Please use this link to pay medical bills.
Form Number: DHA Lemoore NHC (0028)

Munson Army Health Center (0058)

Description: Please use this link to pay medical bills
Form Number: DHA MUNSON AHC (0058)

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