EDI-ERA Enrollment Request Form
Subject
Due Date
Date
Product
Please select...
Accupoint
Apex
Catalyst
Codemetro
Fusion
Fusion Enterprise
KASA
Logik
MCP-Legacy
NewCrop
Procentive
Sharenote
TenEleven
TheraNest Enterprise
TheraNest Lite
TheraNest Professional
WebABA Enterprise
WebABA Group
WebABA Legacy
WebABA Professional
Primary/Corporate Site Name
Site Address Line 1
Site Address Line 2
City
State
Zip Code
Contact Name
First Name
Last Name
Your Email Address
This will be the email to which our enrollment team will be sending all the enrollment details of this project.
Phone Number
Fax Number
Primary Billing NPI
Do you have multiple locations with multiple NPIs?
Please select...
Yes
No
NPI
Payor
Note: You can add multiple payers to this form (once you add the first payer name and payer ID a new box for "Payer 2" will appear and will continue to add payer boxes subsequently up to 25 payers per request form if needed).
Payor ID
Payor Type
Medicare
Medicaid
Commercial
Other
Payor 2
Do you want to enroll for eligibility request 2?
Please select...
Yes
No
Payor ID 2
Payor Type 2
Medicare
Medicaid
Commercial
Other
Payor 3
Do you want to enroll for eligibility request 3?
Please select...
Yes
No
Payor ID 3
Payor Type 3
Medicare
Medicaid
Commercial
Other
Payor 4
Do you want to enroll for eligibility request 4?
Please select...
Yes
No
Payor ID 4
Payor Type 4
Medicare
Medicaid
Commercial
Other
Payor 5
Do you want to enroll for eligibility request 5?
Please select...
Yes
No
Payor ID 5
Payor Type 5
Medicare
Medicaid
Commercial
Other
Payor 6
Do you want to enroll for eligibility request 6?
Please select...
Yes
No
Payor ID 6
Payor Type 6
Medicare
Medicaid
Commercial
Other
Payor 7
Do you want to enroll for eligibility request 7?
Please select...
Yes
No
Payor ID 7
Payor Type 7
Medicare
Medicaid
Commercial
Other
Payor 8
Do you want to enroll for eligibility request 8?
Please select...
Yes
No
Payor ID 8
Payor Type 8
Medicare
Medicaid
Commercial
Other
Payor 9
Do you want to enroll for eligibility request 9?
Please select...
Yes
No
Payor ID 9
Payor Type 9
Medicare
Medicaid
Commercial
Other
Payor 10
Do you want to enroll for eligibility request 10?
Please select...
Yes
No
Payor ID 10
Payor Type 10
Medicare
Medicaid
Commercial
Other
Payor 11
Do you want to enroll for eligibility request 11?
Please select...
Yes
No
Payor ID 11
Payor Type 11
Medicare
Medicaid
Commercial
Other
Payor 12
Do you want to enroll for eligibility request 12?
Please select...
Yes
No
Payor ID 12
Payor Type 12
Medicare
Medicaid
Commercial
Other
Payor 13
Do you want to enroll for eligibility request 13?
Please select...
Yes
No
Payor ID 13
Payor Type 13
Medicare
Medicaid
Commercial
Other
Payor 14
Do you want to enroll for eligibility request 14?
Please select...
Yes
No
Payor ID 14
Payor Type 14
Medicare
Medicaid
Commercial
Other
Payor 15
Do you want to enroll for eligibility request 15?
Please select...
Yes
No
Payor ID 15
Payor Type 15
Medicare
Medicaid
Commercial
Other
Payor 16
Do you want to enroll for eligibility request 16?
Please select...
Yes
No
Payor ID 16
Payor Type 16
Medicare
Medicaid
Commercial
Other
Payor 17
Do you want to enroll for eligibility request 17?
Please select...
Yes
No
Payor ID 17
Payor Type 17
Medicare
Medicaid
Commercial
Other
Payor 18
Do you want to enroll for eligibility request 18?
Please select...
Yes
No
Payor ID 18
Payor Type 18
Medicare
Medicaid
Commercial
Other
Payor 19
Do you want to enroll for eligibility request 19?
Please select...
Yes
No
Payor ID 19
Payor Type 19
Medicare
Medicaid
Commercial
Other
Payor 20
Do you want to enroll for eligibility request 20?
Please select...
Yes
No
Payor ID 20
Payor Type 20
Medicare
Medicaid
Commercial
Other
Payor 21
Do you want to enroll for eligibility request 21?
Please select...
Yes
No
Payor ID 21
Payor Type 21
Medicare
Medicaid
Commercial
Other
Payor 22
Do you want to enroll for eligibility request 22?
Please select...
Yes
No
Payor ID 22
Payor Type 22
Medicare
Medicaid
Commercial
Other
Payor 23
Do you want to enroll for eligibility request 23?
Please select...
Yes
No
Payor ID 23
Payor Type 23
Medicare
Medicaid
Commercial
Other
Payor 24
Do you want to enroll for eligibility request 24?
Please select...
Yes
No
Payor ID 24
Payor Type 24
Medicare
Medicaid
Commercial
Other
Payor 25
Do you want to enroll for eligibility request 25?
Please select...
Yes
No
Payor ID 25
Payor Type 25
Medicare
Medicaid
Commercial
Other
Medicaid Provider ID 2
Tax ID
Taxonomy Number
Billing NPI ID
How Many Individual NPI IDs?
Please select...
1
2
3
4
5
Individual NPI ID
Individual NPI ID 2
Individual NPI ID 3
Individual NPI ID 4
Individual NPI ID 5
Group NPI
Group ID or PTAN ID
Medicaid Provider ID
File Upload
This File upload section can be used to attach documents or screenshots that you think the enrollment team needs to review for your request. You can also upload an excel file with the list of payers if you are looking to enroll on more than 25 payers.
Please enter the details of your request. A member of our support staff will respond as soon as possible.