• Agencies

Medicare Coverage Gap Discount Program CMPs

Description: Please use this form to pay your Medicare Coverage Gap Discount Program Civil Monetary Penalties
Form Number: Medicare CGDP CMPs

OSHA Penalty Payment Form

Description: Use this form to pay your federal OSHA Penalty. Have your inspection number(s) available. This form is not applicable for employers in State Plans. Please contact your local State Plan office for payment instructions.
Form Number: OSHA Penalty Col

BOR California Great Basin (CGB) Permit Fees

Description: Use this form to pay your permit fees. This is NOT an application. Applicants must contact their local park office.
Form Number: CGB Permit Fees

Library of Congress Store

Description: Please use this form to make payments via credit card/debit card (ACH) for Retail Services (RES) Orders.
Form Number: LOC - Retail

FBI State and Local Collections

Form Number: FBI Interagency Agreement Reimbursement

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

Write Your Own Insurance Online Payment Form

Description: Use this form to make a payment to the FEMA's Write Your Own Insurance Program
Form Number: FEMA WYOI

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)

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)

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