Fillable SITE ID: 337G **Required** MEDICAL OFFICE PROVIDER ENROLLMENT (Office Ally)

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SITE ID: 337G **Required** MEDICAL OFFICE PROVIDER ENROLLMENT (Office Ally)

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MEDICAL OFFICE PROVIDER ENROLLMENT FORM
Please complete and return via email to enrollassist@trizetto.com
If you are unable to email this form, please fax it to 314-802-6913.
Please note the turnaround time for approval is 10 Business Days, you will be notified by
Email or Fax, if you have a preference please indicate on the form.
Contact Name:
Phone:
Email:
Fax:
The information provided on this form MUST match what is on file with the payers.
Group Information (if applicable)
Provider Information
Group Name:
First Name:
MI:
DBA (if applicable):
Last Name:
Title:
Group NPI:
Individual NPI:
Tax ID:
Specialty:
Service Location Address
Pay To Address (if different)
Street Address:
Street Address:
City, State, Zip +4:
City, State, Zip +4:
***Indicate below the Individual and/or the Group Provider numbers, legacy ID’s or PTANS issued by the payers. ***
Although these IDs may not be used on the claims, they are often required for EDI enrollment.
Insurance Company
Payer ID
Group Provider Number
Individual Provider Number
Intercommunity Health Net INCHN
SITE ID: 337G
**Required**
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SITE ID: 337G **Required** MEDICAL OFFICE PROVIDER ENROLLMENT (Office Ally)

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Completed 8 April 2021

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