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Please enter the Last Name, First Name/Gender/Birth Date/Enrollment Date/Address Line 1/Address Line 2/City/State/Zip Code/Email/Phone Number. Separate each enrollee with a semicolon. 

Example: Last,First/F or M or U/mm.dd.yyyy/mm.dd.yyyy/Street Address/Apt Number or Suite Number/City/State/Zip Code/email/phone number with no spaces.

Please use this exact format and do not add or omit any elements. Please only enter primary members (no dependents).

To ensure the efficient management of telehealth services within budget constraints, Zero to Five Montana requires that programs abide by the deadlines designated by the payment schedule.

Reminders for updates will go out between the 8th and 10th of the month. Programs will have 7 days to send in updates for enrollees (adding or removing enrollees, updating enrollee information). Invoices will be sent out between the 19th - 21st of the month and need to be paid 3 business days later, between the 22nd - 24th of the month. Payments will be due by midnight on the 24th of the month. If the 24th of the month falls on a weekend or holiday, payment needs to be made by midnight on the last business day before the 24th. If we do not receive your payment by the deadline, the program will be charged a late fee of $10/per enrollee. If we do not receive full payment, including late charges that have accrued, by the 28th of the month, program enrollees will be unenrolled, and programs will have to resubmit an enrollment form for the following month. 

By clicking submit below, you consent to allow Zero to Five Montana to store and process the personal information submitted above to provide you the content requested.