Taxpayer ID Number

Key Field. Enter the taxpayer's ID number.

Taxpayer ID Type

Required. Defaults to [Federal Business ID]. Select [Social Security Number] if taxpayer type is individual.

Taxpayer ID Paid By

Required. Default is [Checkwriter]. Select [Medicaid Services] if payment is made by Medicaid.

Taxpayer ID Category

Required. Default is [Individual]. Select the appropriate category. Valid values include:

Individual

Corporation

Partnership

Not 1099-Reportable

Taxpayer Name

Required. Enter the name of the taxpayer.

Taxpayer Address

Required. Enter the address of the taxpayer. Address line 1 is required. Address line 2 and 3 are optional.

City

Required. Enter the city of the taxpayer.

State

Required. Enter the state of the taxpayer.

Zip Code

Required. Enter the zip code of the taxpayer.

Country

Optional. Enter the country of the taxpayer.