You must complete all required fields on the form as indicated in red

EDI ENROLLMENT

This form is required to be completed for your office to receive an 835/ERA ONLY (this form is NOT for EFT enrollment).  For assistance with registration for the EFT/ERA please contact PaySpan at 877-331-7154 and select option one.

835/ERA Enrollment Form Instructions

Contact us if you have any questions.


* Indicates a required field

PROVIDER INFORMATION
Provider Name
Doing Business as Name (DBA)
PROVIDER ADDRESS
Street
City
State/Province State/Province is required and accepts only alphabet characters
Zip Code/Postal Code Zip Code/Postal Code is required and must be in xxxxx or xxxxx-xxxx format (ex. 12345 or 12345-0001)
PROVIDER IDENTIFIERS
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) TIN/EIN is required and accepts only numeric characters
National Provider Identifier (NPI) NPI is required and accepts only numeric characters
Click to validate the TIN and NPI combination and to expose the Payee ID(s) associated with them. Select at least 1 Payee ID to continue.

PROVIDER CONTACT INFORMATION
Provider Contact Name
Telephone Number
Email Address Provider Contact Email Address is required and must be in abc@xyz.com format (ex.test@mvphealthcare.com)
PROVIDER AGENT INFORMATION
Provider Agent Name
Street
City
State/Province Provider Agent State/Province is required and accepts only alphabet characters
Zip Code/Postal Code Provider Agent Zip Code/Postal Code is required and must be in xxxxx or xxxxx-xxxx format (ex. 12345 or 12345-0001)
Provider Agent Contact Name
Telephone Number
Email Address Provider Agent Email Address is required and must be in abc@xyz.com format (ex.test@mvphealthcare.com)
ELECTRONIC REMITTANCE ADVICE: PREFERENCE FOR AGGREGATION OF REMITTANCE DATA (e.g., Account Number Linkage to Provider Identifier)
Provider Tax Identification Number (TIN) ERA TIN accepts only numeric characters
National Provider Identifier (NPI) ERA NPI accepts only numeric characters
Method of Retrieval
ELECTRONIC REMITTANCE ADVICE: CLEARINGHOUSE INFORMATION
Clearinghouse Name
Clearinghouse Email Address ERA Clearinghouse Email Address must be in abc@xyz.com format (ex.test@mvphealthcare.com)
ELECTRONIC REMITTANCE ADVICE: VENDOR INFORMATION
Vendor Name
SUBMISSION INFORMATION
Enrollment Type
Authorized Signature