EDI CLAIMS ENROLLMENT FORM

IDENTIFICATION OF PROVIDER/TRADING PARTNER AND TRANSACTION INFORMATION

All Trading Partners, whether covered entities or business associates of covered entities, agree to abide by all HIPAA Privacy and Security requirements as they apply to communications with The Alliance.

Reminder: Prior to setting up Electronic Data Interchange (EDI) claims submission with the Alliance, a minimum of one paper claim must have been submitted to the Alliance so that a record for the office can be configured.


PROVIDER INFORMATION (All fields required)
Provider Name:
Provider Federal Tax Identification Number (TIN):
Doing Business As Name (DBA):
National Provider Identifier (NPI):
Provider Address – Street:
City:
State/Province:
ZIP Code/Postal Code:
 
Provider Contact Name:
Telephone Number:
 
Email Address:
 
CLEARINGHOUSE INFORMATION (Required field)(If you select Yes, please enter the name of the clearinghouse)
Are you planning to use a clearinghouse for
electronic transmissions with the Alliance?
Clearinghouse Name:
BILLING SERVICE/VENDOR INFORMATION (Required field)(If you select Yes, please enter the name of the billing service)
Do you currently use a billing service/vendor? Billing Service/Vendor Name:
SUBMISSION INFORMATION (Required field)
Reason for Submission:
TRANSMISSION INFORMATION (Select appropriate fields)


(Check with your clearinghouse for availability)
AUTHORIZED SIGNATURE (Person submitting form)
Name:
Signature:
RadDatePicker
RadDatePicker
Open the calendar popup.

Please EMAIL completed form to edisupport@ccah-alliance.org.
Or FAX to (831) 430-5895, ATTN: EDI Analyst

For questions about this form, please call the EDI Support Group at (800) 700-3874 x5510.