Sandhills Center for MH, DD & SAS
EDI Request or Termination Form
STEP 1: Action Requested:
Action: Request 835 set up Cancel 835 set up Change 835 set up
Request 837I set up Cancel 837I set up Change 837I set up
Request 837P set up Cancel 837P set up Change 837P set up
Set-up (check one) 835 Direct to Provider (continue to Step 3)
835 Direct to Clearinghouse or Billing agency (complete Steps 2 & 3)
Please Print Legibly
STEP 2: Clearing House Information
Effective Date: From: ___________ To: ___________
Clearinghouse Name: _______________________________________________________
Sandhills Center Submitter ID: _______________________________________________
Contact Name: _____________________ Email: _________________________________
Telephone Number: _________________ Fax Number: ____________________________
STEP 3: Provider Information
Date: _________ Sandhills Center Submitter ID: ________________________________
Provider Name: ___________________________________________________________
Contact Name: ______________________ Email: ________________________________
Contact Signature (required if sending via email): _________________________________
Address: _________________________________________________________________
Telephone Number: __________________ Fax Number: _________________________
Printed Name of Provider Signature: ___________________________________________
Tax ID: _____________ Group NPI: ______________ Individual NPI: ______________
Medicaid Provider Number: _______________________________________________
Acknowledgement:
If sending electronically, check this box as acknowledgement as an electronic signature.
Return by eMail to EDI@sandhillscenter.org
This form must be completed by the Provider for the purposes of establishing or terminating the
receipt of the 835 Electronic Remittance Advice and 837 Institutional or Professional Claims files. It is
a requirement that the form be completed and signed off by the Provider.
Only one Tax ID number may be identified per form.
click to sign
signature
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