EDI Enrollment Form

Section 1. Submitter Information

Trading Partner Name

Address Line 1

Address Line 2

City

State

Zip Code

Primary User First Name

Primary User Last Name

Job Title

Primary Phone Number

Ext. No.

Primary Cell Number

Primary E-mail Address

Please select at least one checkbox from the below categories.

Inbound Batch

837-P (Professional Claims)

837-I (Institutional Claims)

270/271 (Eligibility Req/Resp)

276/277 (Claims Status Req/Resp)

Outbound Batch

835(Remittance Advice)/277U (Pended Claim)