Request a Check

Request a Check Form

  • Please complete this form when requesting a check to an agency that includes payments on behalf of multiple clients/members. The check will be processed during normal business hours. C3CAP will let you know when your request is complete along with a confirmation number. You will need to include this confirmation number in the Notes/Comments field of the Service Request you submit in CLARA after the fact. DO NOT USE THIS FORM TO REQUEST PAYMENT ON BEHALF OF ONE CLIENT/MEMBER – PLEASE USE CLARA DIRECTLY INSTEAD.

  • Check Requester Information

  • Check Information

  • Date Format: MM slash DD slash YYYY
  • Mailing Information

  • Notes/Comments