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Form 720
Step
1
of
4
- Create Form
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Quarter Year
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2023
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Quarter 2
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Patient-Centered Outcomes Research Fee
Specified Health Insurance Policies (133A/133B)
(133A) With a policy year ending before 10/1/2022
(133B) With a policy year ending on or after 10/1/2022, and before 10/1/2023
Avg number of lives covered
Rate for covered life
Rate for covered life
Applicable Self-Insured Health Plans (133C/133D)
(133C) With a plan year ending before 10/1/2022
(133D) With a plan year ending on or after 10/1/2022, and before 10/1/2023
Avg number of lives covered
Rate for covered life
Rate for covered life
Tax Amount
Tax Amount
Filing Fee
Product Pricing
Payment
Pay the balance with Electronic Funds Withdrawal (ACH).
You have already paid the balance using EFTPS.
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