ERA Enrollment Form

Instructions for completing the ERA Enrollment Form


Please Note: Due to data privacy requirements, ERA recipient adds/changes must be confirmed with the provider office prior to setup. Failure to provide contact information may result in a delay or denial of your request.

Provider Information
Provider Name*:
Street Address1*:
Street Address2:
City*:
State*: Zip Code*: -
Provider Indentifiers Information

Provider Identifiers

Provider Federal Tax Indentification (TIN) or Employer Identification Number (EIN)*:
National Provider Indentifier (NPI)*:

Other Identifiers

Trading Partner ID*:
Provider Contact Information
Provider Contact Name*:
Telephone Number*: --
Extension:
Email Address*:

Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Indentifier)
National Provider Identification Number (NPI)
Provider Tax Identification Number (TIN)
Reason For Submission
New Enrollment
Change Enrollment
Cancel Enrollment
Authorized Signature
Printed Name of Person Submitting Enrollment
I certify that I am authorized to make this request

Fields marked with an asterisk (*) are required.