Email this form to Support@officeally.com
or Fax to (360) 896-2151. Once your form is received and processed, Office Ally will
email you a confirmation. If you do not receive a confirmation email from us within 2-3 business days or faxing or emailing this form, please
send it again. Please make sure to print legibly and to complete this form in its entirety. You risk delaying enrollment if the application is
unreadable or incomplete. All fields in bold are required.
Provider Name:
Provider Address: City: State: Zip:
Provider Federal Tax Identification Number
Employer Identification Number (EIN): National Provider Identifier (NPI):
Contact Name: Telephone Number/Extension:
Email Address: Fax Number:
Authorized Signature:
Note: Electronic Signature (Typed Name) of Person Submitting EDI Enrollment.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
GOLD COAST EDI ENROLLMENT
REQUEST
PROVIDER INFORMATION
PROVIDER IDENTIFIERS INFORMATION
PROVIDER CONTACT INFORMATION
