Office Ally submits electronically t
o a vast number of payers (our Payer Lists are available on our website under
Resource Center: Payer Lists), but in some cases there are payers that we have not yet connected to or certain
lines of business that have not yet been added. Please use this form to request a payer (or additional line of
business for an existing payer) be added to our payer list. Complete the below fields and email the form back to
us at Support@officeally.com. Once we receive this form, we will review the information and look into whether
a connection with the requested payer is possible. Forms lacking required information will not be considered.
Connection to the payer requested is not guaranteed.
Requestor’s Name*:
Requestor’s Phone:
Requestor’s Email*:
Monthly Claim Volume:
Requested Connection*:
Professional I
nstitutional Dental
ERA
Rea
l Time Eligibility (270/271) Real Time Claim Status (276/277)
Payer Name*:
Payer ID*:
Payer Phone*:
Payer Address:
Additi
onal Notes
:
*Fields denoted with an asterisk are required
NEW PAYER CONNECTION REQUEST FORM
Office Ally | P.O. Box 872020 | Vancouver, WA 98687
www.officeally.com
Phone: 360-975-7000
Fax: 360-896-2151
