Email this form to Support@officeally.com
. The Email Subject should read: UHIN EDI Enrollment. Please make sure to print
legibly and to complete this form in its entirety. Standard processing time is 10 business days. You risk delaying enrollment if the
application is unreadable or incomplete. All fields in bold are required.
Provider Name:
Provider Address: City: State: Zip:
Provider Federal Tax Identification Number
Employer Identification Number (EIN): National Provider Identifier (NPI):
Contact Name: Telephone Number/Extension:
Email Address: Fax Number:
Provider Address: City: State: Zip:
SX105 - Deseret Mutual Benefit Administrators
(Professional claims only)
VHP01 - Valley Health Plan (Commercial)
(Professional and Institutional claims)
VHP02 - Valley Health Plan (Medi-Cal)
(Professional and Institutional claims)
Authorized Signature:
Note: Electronic Signature (Typed Name) of Person Submitting EDI Enrollment.
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
UHIN EDI
ENROLLMENT FORM
PROVIDER INFORMATION
PROVIDER IDENTIFIERS INFORMATION
PROVIDER CONTACT INFORMATION
PAYER NAMES (CHECK ALL THAT APPLY)
SUBMISSION INFORMATION
PROVIDER PHYSICAL ADDRESS (if different from above)
