Update ERA Enrollment Form

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Update ERA Enrollment Form

Update ERA Enrollment Form

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.

All fields with (*) are required

Select the tabs on the left to fill out the information in those sections

Provider Information

Provider Name*

Street Address1*

Street Address2

City*

State*

Zip*

Provider Identifiers Information

Provider Identifiers

Provider Federal Tax Identification (TIN) or Employer Identification Number (EIN)*

National Provider Identifier (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 Identifier)

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