| Electronic Data Interchange Enrollment and Change Form
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| Section 1: Reason for Request
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| Effective Date of Requested Change:
Date of this screening:
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| Section 1A: (For New Setups Only) New EDI Setup Requests
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| New Setup Claims Submission (837)
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Professional
Institutional
Both
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| New Setup Remittance Advice (835)
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Professional
Institutional
Both
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| Section 1B: (For Existing Setups) Existing EDI Setup Change Requests
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| Add Provider(s) to (837) Claim EDI setup
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837- Professional
837- Institutional
Existing Submitter ID# |
| Add Provider(s) to (835) Remittance EDI setup |
835- Professional
835- Institutional
Existing Submitter ID#
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| Section 2: Clearinghouse Information
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| Please select an Option:
New Vendor/Clearinghouse
Existing Vendor/Clearinghouse
Change of Vendor/Clearinghouse
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| Vendor/Clearinghouse Name:
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| Vendor/Clearinghouse Primary Contact Name:
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| Primary Contact Telephone #:
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| Primary Contact E-Mail Address:
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| Existing Submitter ID#:
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| Previous Vendor/Clearinghouse Name:
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if not applicable enter "none"
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| Previous Vendor/Clearinghouse Submitter ID#:
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if not applicable enter "none"
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| Section 3: Faculty/Group Practice/Individual Provider Information
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| Please select an Option:
New Provider Information
Update/Change Existing Provider Information
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| Facility/Practice/Provider Name:
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| Provider Primary Contact Name:
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| Provider Primary Contact Telephone #:
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| Provider Primary Contact E-mail:
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| Provider(s) Tax ID:
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| National Group Provider Identifier (NPI):
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| Existing Submitter ID#:
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if not applicable enter "none"
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| Verify the information above is correct. Then click
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Unlock form for editing.
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| Today's Date |
Document Reference Number:
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