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Click ‘Get Form’ to open the 835 ENROLLMENT REQUEST in the editor.
Begin by filling out the PROVIDER INFORMATION section. Enter your Provider Name, Address, City, State, and Zip Code. Ensure all entries are legible.
Next, complete the PROVIDER IDENTIFIERS INFORMATION. Input your Employer Identification Number (EIN) and National Provider Identifier (NPI). These identifiers are crucial for processing your enrollment.
In the PROVIDER CONTACT INFORMATION section, provide a Contact Name, Telephone Number/Extension, Email Address, and Fax Number for any follow-up communications.
For ELECTRONIC REMITTANCE ADVICE INFORMATION, select your preference for aggregation of remittance data. Choose only one option that matches your EFT payment preference.
Fill out the SUBMISSION INFORMATION section by indicating the Reason for Submission and providing an Authorized Signature. Remember that an electronic signature can be typed in this field.
Finally, review all fields to ensure completeness and clarity before submitting via email or fax as instructed at the top of the form.

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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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