835 ERA Enrollment Form
835 ERA Enrollment Form Instructions
Provider Name: Enter the individual provider name or group name (if billing under a group).
Provider Address: Enter your physical address information.
TIN/EIN: Enter your Tax ID Number.
Trading Partner ID:
Clearinghouse or Billing Service, you must enter their Trading Partner ID. If you are downloading to your
account then it should be your Provider Trading Partner ID. If you are establishing your own new account
Provider Taxonomy Code: Enter your ten position alphanumeric taxonomy code.
Enter the name and contact information for the EDI Coordinator to use if there are questions about the information
on this form.
Billing Agent Information
If you are using a billing agent other than that supplied in the Provider Address and Contact information sections,
please enter agent information in this section.
Electronic Remittance Advice Clearinghouse Information
Electronic Remittance Advice Vendor Information
Enter the reason for the form subission.
Authorized Signature: The provider or a provider representative (not a vendor or clearinghouse) must sign this
Name: The provider or a provider representative should print their name
Title: The provider or a provider representative should print their title
Return by E-mail email@example.com