PCORI Fee Reporting Services for Existing BPC Clients

Please complete the form below and your Benefit Specialist will contact you to complete your report.

Upon completion of your report, you will be charged $150.00 on your next monthly invoice. Orders after July 7th are considered rush orders and will cost $300.

Please read the Provider Service Agreement for PCORI Fee Reporting and Compliance. You will be asked to confirm your acceptance below.

Are you a current BPC client?

Yes

Company

Contact Name

First Name

Last Name

Phone

(###)

###

####

Additional Comments

Please place your initials in the box below to acknowledge that you have read and accept the Provider Agreement for PCORI Fee Reporting and Compliance that is linked above this form.