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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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  3. Fill out the blank areas; involved parties names, places of residence and phone numbers etc.
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  5. Add the day/time and place your e-signature.
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Keywords relevant to Fsatpa

  • remitted
  • certify
  • participant
  • Invoice
  • recurring
  • Mailing
  • Termination
  • documentation
  • provider
  • Tribal
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