Please fax completed Print Option Update Form to (360) 314-2184. For questions call (360) 975-7000 opt. 3.
2018-06-22 *Rates are subject to change
In order to modify your current print option this form must be completed in its entirety. Incomplete forms will not be processed.
Complete forms will be processed within 48 business hours of receipt. Once the change has been made an email confirmation will be
sent to the email address on file. If it has been more than 48 hours and you have not received confirmation please call Customer
Service at (360) 975-7000 opt. 1 to confirm that Office Ally has received your Print Option Update Form.
TERMS/CONDITIONS:
• The selection made on this form will supersede the selection(s) made on any previous Authorization Sheet or Print Option
Update Form.
• Pre-Enrollment Requirement: Certain payers require pre-enrollment which must be completed and approved before claims
can be sent electronically. See our payer list
for a complete listing.
CLAIMS PRINTING POLICIES:
• All claims that Office Ally is able to submit electronically are done so FREE OF CHARGE.
• Any claims that Office Ally has to print and mail are done so at a rate of $ 0.45 cents per claim* if you select this option
below.
• Claims that need to be printed and mailed to individuals (such as patients or attorneys), or to foreign countries will be
charged a rate of $0.55 per claim*.
• The submitter will be invoiced monthly via email for these paper claims.
ELECT PRINTING OPTION: YOU ARE REQUIRED TO MAKE A CHOICE BELOW (CHECK ONLY ONE)
Do not print any claims for me. I understand that if I transmit claims that cannot be sent electronically, they may be
rejected back to me.
I hereby allow Office Ally to print and mail to the appropriate payers the claims that are not accepted electronically
as indicated on the payer list and the provider’s pre-enrollment status. I agree to pay Office Ally $0.45/claim* for
claims sent to insurance companies/payers and $0.55/claim* for claims sent to individuals (such as patients or
attorneys) or to foreign countries. I further understand it is my responsibility to ensure that all pre-enrollment forms
are properly completed, submitted and approved, and that Office Ally is aware of the approval. Claims I submit to
payers that require pre-enrollment, where the approval has not been logged in Office Ally’s system, will be printed
and mailed at my expense.
By signing below, you are acknowledging that you have read, understand, and agree to all terms/conditions in full.
Signature (Owner of Account or President/CEO/Owner of Practice/Facility)
Name (Owner of Account or President/CEO/Owner of Practice/Facility)
Title (President/CEO/Owner of Practice/Facility)
