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Echo ansi 835 enrollment form 2025

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The document is an ECHO ANSI 835 Enrollment Form used for new Electronic Remittance Advice (ERA) enrollment by healthcare service providers. It collects essential information such as provider details, billing address, tax ID, payer names, and contact information. The form also includes options for electronic 1099 acceptance and requires approval from an authorized person.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (220 Votes)

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