Get Electronic Data Interchange (edi) Enrollment (8292jh). Edi Enrollment Form To Enroll For Electronic

Filling out the Electronic Data Interchange (EDI) Enrollment (8292JH) form is essential for providers wishing to enroll for electronic billing. This guide offers a step-by-step approach to ensure accuracy and ease in completing the form.

Follow the steps to successfully fill out the EDI Enrollment form.

1. Click ‘Get Form’ button to access the EDI Enrollment form and open it in your preferred online editor.
2. Enter the required information in the Provider Organization section, including practice or facility name, provider name, tax ID, client ID, site ID, address, city, state, zip code, contact name, and email address.
3. Complete the telephone and fax fields in the contact information section. Ensure accuracy in the details provided.
4. In the Vendor section, specify the Emdeon certified vendor details including vendor submitter ID, vendor name, division ID, contact name, and email address.
5. Fill in the Payer information by entering the payer ID, group ID, and individual provider ID as required.
6. Input your National Provider Identifier (NPI) and any specific confirmations needed to receive Emdeon claim confirmations.
7. Ensure all fields marked with an asterisk (*) are completed, as these are mandatory for the enrollment process.
8. Address any special instructions related to the enrollment, if applicable, to clarify your preferences.
9. Finally, print the completed form, add your signature, date it, and then submit it either via fax or email as outlined in the submission instructions.
10. After submission, remember to save a copy of the completed form for your records and to facilitate future inquiries about your enrollment status.

Complete the Electronic Data Interchange (EDI) Enrollment form online today to streamline your billing process.