EDI SIGNUP FORM
Practice Profile
Provider Profile
EDI Agreement
Practice Profile
Name of Practice
License
5 Digit Code
Email
Suite#
Address
City
State
Zip
Office Phone
Fax
NPI
Website
Is this Practice currently transmitting claims electronically?
If so, how (direct to payor or through a clearinghouse)?
Name of previous clearinghouse?
If using Relay Health/McKesson what is the Submitter ID?
Anticipated cutoff from current clearinghouse?
eClaims Activation Date
ERA Activation Date
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Provider Profile
Monthly Estimated Claim Volume
Primary Provider Code
Provider First Name
Provider Last Name
Bill As Provider
Title
Suite#
Remittance Address
City
State
Zip
Office Phone
Fax
Group Code
License
Tax ID
CLIA
UPIN
Taxonomy
NPI
Next
EDI Agreement
CPID
Carrier
State
Claims, Remittance or Both
Claims only
Remittances only
Both
Group/Individual
Individual
Group
Name of Group / Individual
Physical / Service Address
Pay to Address (if any)
Individual PTAN / Provider ID
Group PTAN / Provider ID
NPI
Tax ID
Contact First Name
Contact Last Name
Contact Email
Contact Phone
Contact Fax
Provider Signee
Title
Current EFT?
Yes
No
Setup EFT?
Yes
No
Submit