TPA Application

REQUEST FOR CERTIFICATION TO TREAT TPA PURSUANT TO NRS 636.2895
Download Form
Upload Form*
Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 10 MB, Max. files: 20.
Maximum File Size limit 10 MB
Fee
Price:
Processing Fee (3.5%)
Price: $0.00
Total
$0.00
Name*
First
Date
MM slash DD slash YYYY
Billing Address*
Street Address City State ZIP Code
Credit Card

American Express
Discover
MasterCard
Visa
JCB
Maestro
Supported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro
Card Number Expiration Date Security Code Cardholder Name
NOTE: To avoid the processing fee, payments may be made by mail, enclosing a check payable to NV State Board of Optometry, noting the purpose of the payment and the name of the license. However, the Board prefers that all applications, documents or forms be submitted electronically. No submissions will be processed or deemed submitted until payment has been received.
Privacy Policy

All information is Protected and secured.