Initial Here:
I understand that for each unique Tax ID + Rendering NPI combination (if no Rendering NPI is present,
then for Institutional claims Attending NPI will be used. Otherwise, Billing NPI will be used for this calculation when Rendering
NPI/Attending NPI is not present) whose claim volume is 50% or more to Non-Par Payers (per our Payer List) in a month, the
Non-Par processing fee of $35.00* will be charged for that unique Tax ID + Rendering NPI combination for that month.
SEPARATE USERNAME REQUEST
(For Existing Users Only)
Current Office Ally Username:
*If you do not have a current username, please complete our online enrollment form or call to speak to an enrollment specialist.
SECTION 1: ACCOUNT INFORMATION
Preferred User Name: *Office Ally cannot guarantee that this username will be available.
SECTION 2: PROVIDER INFORMATION
Main Contact: (Contact information on new username will be identical to current username unless new contact information is provided here)
Contact Name Contact Email Contact Phone Number
Contact Name Contact Email Contact Phone Number
Authorized Contact: (Contact information on new username will be identical to current username unless new contact information is provided here)
Send Invoices to this Authorized Contact?
Solo Provider Name or Group Name:
*To add additional Authorized Contacts click here and complete the additional from. Note: The form must be returned with this Separate Username Request form in order to be processed.
Yes No
SFTP Setup Do you need an FTP/SFTP account created?
If Yes, what is the name of the software uploading claims?
Yes No
Note: At least one Authorized Contact must be set to receive invoices.
The information provided will reflect on new username unless otherwise specified. You may make copies of this sheet as needed.
SECTION 3: PRINT OPTION ELECTION, GOV/NON-PAR CLAIMS POLICY ACKNOWLEDGMENT & FTP/SFTP SETUP
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.
Non-Par Claims Policy
Would you like to group this to your Grouped Account?
If Yes, what is the Grouped Account # (It should start with an A):
Yes No
Signature (Owner of Account or President/CEO/Owner of Practice/Facility)
Name (Owner of Account or President/CEO/Owner of Practice/Facility)
Date
Title (President/CEO/Owner of Practice/Facility)
Please submit this completed form by fax to (360) 314-2184 or by email to:
EnrollmentAdmin@OfficeAlly.com
For questions call (360) 975-7000 opt. 3.
*Rates and Payer List are subject to change. OA 2019-05-28
