2022 Electronic Remittance Advice Registration

To authorize Priority Health to send HIPAA compliant Electronic Remittance Advice (ERA) 835 transactions, please complete and submit this form.

ERA receiver information

1. Name of practice/facility billing/pay-to information as it appears on your claims: *This question is required.

2. Tax ID *This question is required.

3. Group NPI *This question is required.

4. Address *This question is required.

5. City *This question is required.

6. State *This question is required.

7. Zip *This question is required.

8. Is there more than one group/organization that will be paid under the above tax ID? *This question is required.

Office contact person

9. First name *This question is required.

10. Last name *This question is required.

11. Phone number *This question is required.

12. Email *This question is required. This question requires a valid email address.

Transmission/routing of ERA files

13. Which clearinghouse will be used? *This question is required.

14. Registration submitter signature *This question is required.Please sign in the space provided and type your name below your signature.

Signature of

Electronic remittance advice registration form