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Electronic Remittance Advice(ERA) Authorization Agreement

* Indicates Mandatory Field

You must Print, Sign and Mail the ERA Form before it is considered Submitted.


Section 1: Provider Specific Information
CLASSIFICATION
*Classification
Individual Provider    Group Provider Practice   
Individual Pharmacy    Branch Pharmacy    Corporate Pharmacy
*Submission Method/Type of Service Used
WINASAP5010     Vendor Software     Billing Agent     Clearinghouse    
If Vender Sofware is selected, in addition to completing Section 7, please provide the following:
Software Name: Software Version: Protocol:

Section 2: Provider Information
*Provider Name:
Doing Business As Name (DBA):
PROVIDER ADDRESS
*Street:
*City: *State: *Zip:

Section3: PROVIDER IDENTIFIERS INFORMATION
PROVIDER IDENTIFIERS
*Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): *Confirm Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):
National Provider Identifier (NPI): Confirm National Provider Indentifier (NPI):
OTHER IDENTIFIER(S)
*Assigning Authority:
Department of Health Care Finance
*Medicaid Provider ID: *Confirm Medicaid Provider ID:
If you are currently submitting electronic transactions directly to Conduent EDI Solutions, please enter your Conduent EDI Solutions 5-digit Submitter ID or 6 - digit Trading Partner ID.

If you are submitting electronic transactions through a Software Vender, Clearinghouse or Billing Agent, please enter their 5-digit Submitter ID or 6 - digit Trading Partner ID.
*Trading Partner ID: *Confirm Trading Partner ID:

Section 4: PROVIDER CONTACT INFORMATION
*Provider Contact Name:
*Telephone Number: Telephone Number Extension:
*Email Address: (If you do not have an email address, please enter ‘NONE’.)

Section 5: ELECTRONIC REMITTANCE ADVICE INFORMATION
*Preference for Aggregation of Remittance Advice Date Account Number Linkage To Provider Identifier (Select one)
Provider Tax Identification Number (TIN): Confirm Provider Tax Identification Number (TIN):
National Provider Identifier (NPI): Confirm National Provider Indentifier (NPI):
*Method of Retrieval: (required if not using an intermediary Billing Agent, Clearinghouse of Software Vender)
EDIONLINE     GrabIT     WINASAP     DC Web Portal    

Section 6: ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION
*Clearinghouse Name:
Clearinghouse Contact Name:
Telephone Number: Email Address:

Section 7: ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION
*Vendor Name:
Vendor Contact Name:
Telephone Number: Email Address:

Section 8: SUBMISSION INFORMATION
*Reason for Submission:
New Enrollment     Change Enrollment     Cancel Enrollment    

AUTHORIZED SIGNATURE I herby declare that the information provided is true and accurate in all respects. I hereby appoint the Billing Agent/Clearinghouse identified above to agent as the authorized agent for the purposes of retrieving health care responses electronically from Conduent EDI Solutions. The Billing Agent/Clearing house is also authorized to access the X12N835 Healthcare Claims Payment Advice
*Printed Name of Person Submitting Enrollment:
*Printed Title of Person Submitting Enrollment:
*Submission Date:
Requested ERA Effective Date: