Request Payor Information Sheet Page

This window allows you to request that a Payor Information Sheet be sent to the address on record for the payor.

Payor Information Sheets can only be sent to the address on file with HFS for the payor entered.

You must enter all required fields, and in the correct format. See below for a list of fields and validation rules.

Field Name	Definition	Validation Rules	Field Type
Payor Number	the HFS identification number of the payor for which you want the Payor Information Sheet	Required.	Text Box
Payor Name	the name of the payor for which you want to request the Payor Information Sheet	Required.	Text Box
Payor Address	the address of the payor for which you want to request the Payor Information Sheet	Required.	Text Box
Payor Second Address	the address of the payor for which you want to request the Payor Information Sheet	Not Required.	Text Box
City	the city of the payor for which you want to request the Payor Information Sheet	Required.	Text Box
State	the state of the payor for which you want to request the Payor Information Sheet	Required.	Dropdown Box
ZIP	the ZIP code of the payor for which you want to request the Payor Information Sheet	Required.	Text Box
Your Name	your first and last name	Required. This information will be entered for you.	Text Box
Phone	a phone number where you can be contacted	Required.	Text Box
E-Mail	your e-mail address where you can be contacted if necessary	Required.	Text Box