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Electronic Remittance Advice Request

Click here for Instructional PDF.


* Required
   

Provider Information
*Provider Name
Provider Address
* Street
*City
*State/Province
*ZIP Code/Postal Code
Provider Identifiers Information
*Provider Federal Tax Identification Number (TIN) or Employer Identification Number(EIN)
National Provider Identifier NPI
Other Identifiers
*Assigning Authority
Trading Partner ID
Provider Contact Information
*Provider Contact Name
*Telephone Number
*Email Address
Fax Number
Preference for Aggregation of Remittance Data(e.g Account Number Linkage to Provider Identifier)(Must match EFT Preference) Provider Tax Idenfication Number(TIN)
National Provider Idenfication Number(NPI)
Provider Tax Idenfication Number(TIN)
National Provider Idenfication Number(NPI)
Electronic Remittance Advice Information
*Clearing House Name
*Telephone Number
*Email Address
*Reason for submission New Enrollment
Change Enrollment
Cancel Enrollment