Fillable Form 2: X12 270/271 X12 834 * X12 (Sanford Health Plan)

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Form 2: X12 270/271 X12 834 * X12 (Sanford Health Plan)

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HP-3345 10-19
Requested Transactions:
X12 270/271
X12 820
X12 277ca
X12 834 *
2
X12 276/277
X12 997/999
X12 837 Professional *
1
X12 837 Institutional *
1
X12 837 Dental *
1
*
1
Will you be using a clearing house (yes/no)?___________________
*
2
Will you be sending Full or ACD files? ______________________
Frequency of Files (Daily/Weekly/Bi-weekly/Monthly)? _____________________________
Complete all below: Complete all fields
Group Name: __________________________________________________________________________
Vendor Name: _________________________________________________________________________
Vendor Address: ________________________________________________________________________
City_________________________________________ State ______________ Zip Code _____________
Technical Contact Business name: ___________________________________________________________
Technical representative name: _____________________________ Phone number: ____________________
Technical representative email address: ________________________________________________________
PO Box 91110
Sioux Falls, SD 57109
(605) 328-6800 1-800-752-5863
Fax: (605) 328-6840
sanfordhealthplan.com
sanfordhealthplan.com
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Form 2: X12 270271 X12 834 * X12 (Sanford Health Plan)

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Completed 20 May 2021

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