CREATING HEALTH CARE SOLUTIONS
EDI CLAIMS ENROLLMENT FORM
IDENTIFICATION OF PROVIDER/TRADING PARTNER
AND TRANSACTION INFORMATION
All Trading Partners, whether covered entities or business associates of covered entities, agree to abide by all HIPAA Privacy and
Security requirements as they apply to communications with The Alliance.
Reminder: Prior to setting up Electronic Data Interchange (EDI) claims submission with the Alliance, a minimum of one paper
claim must have been submitted to the Alliance so that a record for the office can be configured.
PROVIDER INFORMATION (All fields required)
Provider Federal Tax Identification Number (TIN)
Doing Business As Name (DBA)
National Provider Identifier (NPI)
Provider Address – Street
CLEARINGHOUSE INFORMATION (Required field)
Are you planning to use a clearinghouse for electronic
transmissions with the Alliance?
SUBMISSION INFORMATION (Required field)
Reason for Submission:
TRANSMISSION INFORMATION (Select appropriate fields)
(ASC X12N 005010X222)
(ASC X12N 005010X0223)
AUTHORIZED SIGNATURE (Person submitting form)
Please EMAIL completed form to
Or FAX to (831) 430-5895, ATTN: EDI Analyst
To enroll in electronic claims submissions,
please contact our EDI Support Unit by
emailing a completed EDI Claims Enrollment
To enroll in Electronic Remittance Advice(ERA),
contact our partner ECHO Health at
EDI@echohealthinc.com or call (888) 983-5574.
Office Ally, Inc (330897513)