ERA Enrollment Request

Refer to the On-Line enrollment user guide related to the Line of Business you are submitting to.

* = Required Field

DEG 1: Provider Information
Provider Name:*

Doing Business As (DBA):

Provider Address:
Street:*

City:*

State/Province:

ZIP Code/Postal Code:

Country Code:


DEG 2: Provider Identifiers Information
Provider Federal Tax Identification Number (TIN)
or Employer Identification Number (EIN):*

National Provider Identifier (NPI):

Other Identifier(s):

Assigning Authority:*

Trading Partner ID:*

Provider License Number:

License Issuer:

Provider Type:

Provider Taxonomy Code:


DEG 3: Provider Contact Information
Provider Contact Name:*

Title:

Telephone Number:*

Extension:

Email Address:*

Fax Number:


DEG 4: Provider Agent Information
Provider Agent Name:

Agent Address:
Street:


City:

State/Province:

ZIP Code/Postal Code:

Country Code:

Provider Agent Contact Name:

Title:

Telephone Number:

Extension:

Email Address:

Fax Number:


DEG 5: Federal Agency Information
Federal Program Agency Name:

Federal Program Agency Identifier:

Federal Agency Location Code:


DEG 6: Retail Pharmacy Information
Pharmacy Name:

Chain Number:

Parent Organization ID:

Payment Center ID:

NCPDP Provider ID Number:

Medicaid Provider Number:


DEG 7: Electronic Remittance Advice Information
Preference for Aggregation of Remittance Data:
Provider Tax Identification Number (TIN):

National Provider Identifier (NPI):

Method of Retrieval:


DEG 8: Electronic Remittance Advice Clearinghouse Information
Clearinghouse Name:

Clearinghouse Contact Name:

Telephone Number:

Email Address:


DEG 9: Electronic Remittance Advice Vendor Information
Vendor Name:

Vendor Contact Name:

Telephone Number:

Email Address:


DEG 10: Submission Information
Reason for Submission:*

Authorized Signature
Printed Name of Person Submitting Enrollment:*

Submission Date:

01/16/2017

Requested ERA Effective Date:*

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