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.

Note: please use Microsoft Edge or Google Chrome browsers when submitting requests


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)(Please enter the name of the clearinghouse)
Clearinghouse name for electronic transmissions with the Alliance: Clearinghouse Name:
SUBMISSION INFORMATION (Required field)
Reason for Submission:
TRANSMISSION INFORMATION (Select appropriate fields)

AUTHORIZED SIGNATURE (Person submitting form)
Name:
Signature:
Date:

To enroll in Electronic Remittance Advice(ERA), contact our partner ECHO Health at https://enrollments.echohealthinc.com/EFTERAInvitation.aspx?ReturnUrl=%2f or call (888) 834-3511.