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835 enrollment request

Email this form to Sushanthi Cetty scetty - Office Ally 2026

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4.5 out of 5

21 votes

The document is an enrollment request form for providers to submit their information for electronic remittance advice (ERA) enrollment. It includes sections for provider details, identifiers, contact information, and submission reasons, along with a requirement for an authorized signature.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the PROVIDER INFORMATION section. Enter the Provider Name, Address, City, State, and Zip code accurately.
Next, move to PROVIDER IDENTIFIERS INFORMATION. Input the Provider Federal Tax Identification Number (EIN) and National Provider Identifier (NPI). Ensure these numbers are correct for proper identification.
In the PROVIDER CONTACT INFORMATION section, provide the Contact Name, Telephone Number/Extension, Email Address, and Fax Number. This information is crucial for communication purposes.
For ELECTRONIC REMITTANCE ADVICE INFORMATION, select your preference for aggregation of remittance data. Choose only one option that matches your EFT payment preference and fill in either the TIN or NPI as required.
Finally, complete the SUBMISSION INFORMATION section by stating the Reason for Submission and providing an Authorized Signature. Remember that an electronic signature can be a typed name.

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Versions	Form popularity	Fillable & printable
2020	4.5 Satisfied (21 Votes)
2018	4.3 Satisfied (36 Votes)
2017	4 Satisfied (53 Votes)

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Email this form to Sushanthi Cetty scetty - Office Ally 2026

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