Electronic Remittance Advice Registration

Electronic remittance advice registration form

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

ERA receiver information

1. 1. Name of practice/facility billing/pay-to information as it appears on your claims:

2. 2. Tax ID

3. 3. Group NPI

4. 4. Address

5. 5. City

6. 6. State

7. 7. Zip

Office contact person

8. 9. First name

9. 10. Last name

10. 11. Phone number

11. 12. Email address

Transmission/routing of ERA files

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

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

Signature of