Online 835 Registration Form

*Required

Provider Information

Provider Name

Provider Address

Street City State --Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code/Postal

Provider Identifiers

Provider Federal Tax Identification Number (TIN)
or Employer Identification Number (EIN) National Provider Identifier (NPI)

Other Identifiers

Trading Partner ID

Provider Contact Information

Provider Contact Name Telephone Number Telephone Number Extension Email Address

Provider Agent Information

Provider Agent Name Provider Agent Contact Name Telephone Number Telephone Number Extension Email Address

Electronic Remittance Advice Information

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)

Provider Tax Identification Number (TIN) National Provider Identifier (NPI)

Electronic Remittance Advice Clearinghouse Information

Clearinghouse Name

Electronic Remittance Advice Vendor Information

Vendor Name

Submission Information

Reason for Submission --Select One-- New Enrollment Cancel Enrollment Change Enrollment Name of Authorized Person Submitting Enrollment Title of Person Submitting Enrollment Requested ERA Effective Date