Skip survey header

2022 Electronic Remittance Advice Registration

Electronic remittance advice registration form

To authorize Priority Health to send HIPAA compliant Electronic Remittance Advice (ERA) 835 transactions, please complete and submit this form.
ERA receiver information
Office contact person
This question requires a valid email address.
Transmission/routing of ERA files
14. Which clearinghouse will be used? *This question is required.
15. Registration submitter signature *This question is required.Please sign in the space provided and type your name below your signature.
Signature of