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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