Fillable Provider Remittance Advice (RA)

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Provider Remittance Advice (RA)

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Provider Remittance Advice (RA)
Paper Suppression Preference
Provider/Office Name:
TIN:
I would prefer to:
Suppress paper remittance advice from being sent to my location
Receive paper remittance advice at my location
If you would like this change to affect only specific policies, please provide the policy
number:
Requestor’s Name:
Requestor’s Telephone #:
Please be advised, this request may take up to 10 business days to take effect.
Thank you
Payer ID:
UMR01 (Internal use only)
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Provider Remittance Advice (RA)

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Completed 20 April 2021

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