A new trading partner may only be requested by the Trading Partner Administrator.
Administrator Information
In order to confirm your identity for security purposes, please choose one of the following security questions and provide your corresponding security answer. As the Trading Partner Administrator, you will need to provide your security answer each time you request changes or information on behalf of this trading partner.
As the Trading Partner Administrator you may also identify one or more Trading Partner Delegates that can act on your behalf to request basic changes or information for this trading partner.
Delegate Information
Trading Partner Information
Trading Partner Type*:
Provider Information*
Please be advised that updating ERA for this NPI number will result in a change for all
associated providers regardless of where they are currently receiving remittance.
Please fill in the appropriate provider-related fields and click the 'Add Provider' button to record the provider.
Professional Transactions
Institutional Transactions
Software Vendor Information
Acceptance and Submission
Please verify the information you have entered before continuing to submission page.