Submit Your Completed Assignment of Payment Form

Below is the secure upload tool for submitting completed Assignment of Payment and related forms for outpatient diagnostic facility services. Use this tool to securely submit your Assignment of Payment and Medical Director Authorization and related forms (e.g. Confirmation of Practitioner Credentialing, Notification of Medical Directorship Change, Cancellation of Assignment of Payment).

When submitting an Assignment of Payment, please ensure the form is complete and signed by the practitioner, payee representative and departmental or regional Medical Director or their delegate. Only fully completed and authorized Assignment of Payment forms can be processed. If confirmation of practitioner credentialing is needed, it MUST be submitted at the same time as the related AOP form or the AOP cannot be processed. If you need assistance in completing an Assignment of Payment form, consult the Assignment of Payment Completion Checklist (PDF, 419KB).


  • You can upload and send up to 5 separate Assignment of Payment (or related) forms
  • Each form must be saved as a separate document in an approved file format (PDF; JPG; PNG; GIF; BMP)
  • Each file must be named for the practitioner who is named on the Assignment of Payment (or related) form.
  • In naming files, please:
    • Use the practitioner's last name then first name
    • Use lower case letters only
    • Use dashes "-" to separate names (do not use spaces or underscores)
    • Do not use special characters including spaces, commas, underscores or periods
    • Example of proper naming convention: smith-john; brown-susan; white-bob

To submit a completed form:

  1. Scan the form and save a digital copy to your computer in an approved file format using the required naming convention (see information above)

  2. Complete all contact information fields below

  3. Click "Browse" and locate the scanned form on your computer. Click "Add file" to add additional forms to a maximum of 5 separate Assignment of Payment, or related, forms

  4. Submit form(s)

To report any issues with the upload tool, please email:

Add file

Last Revised: January 10, 2019