Please correct the following errors in the form:

Please select the correct Provider Classification

Please enter the Providers Contact Email Address. If you do not have an email address, please enter ‘NONE’.

Please enter the Providers Contact Telephone Number

Please enter the Submmitters National Provider Identifier(NPI) or Provider Tax Identification Number(TIN)

Please enter the Submmitters National Provider Identifier(NPI) or Provider Tax Identification Number(TIN)

Please select the Method of Retrieval

Please enter the Providers City

Please enter the Providers State or Province

Please enter the Providers Street

Please enter the Providers Zip Code or Postal Code

Please enter the Provider Contact Name

Please enter the Providers Medicaid ID

Please enter the Providers Name

Please enter the Providers National Provider Identifier(NPI)

Please enter the Providers Federal Tax Identification Number(TIN) or Employer Identification Number(EIN)

Please Select Reason for Submission

Please select a Submission Method/Type of Service Used

Please enter the Submission Date in MM/DD/YYYY format

Please enter the Submitter Name

Please enter the Submitter Title

Please enter the Trading Partners ID

* 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:	Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNon US - Other CountryNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming	*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:

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