Get Submitterclient Relationship For Electronic Claim Submission Application For An Accredited

Filling out the SubmitterClient Relationship for Electronic Claim Submission Application For An Accredited is essential for processing claims electronically. This guide will provide clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name and business address of the contract holder in the designated fields. Make sure to provide accurate details to ensure proper identification.
3. Fill in the proposed commencement date. This date signifies when you wish the electronic claims to begin being processed under this application.
4. In the contact name and contact phone number fields, enter the relevant person's information. This contact will be reached for any queries regarding the application.
5. If applicable, include the BA number(s) as required, following the notes provided to ensure compliance with the guidelines.
6. For the submitter's section, enter the submitter name, prefix code, and ULI number accurately. This information is crucial for the electronic claim submissions.
7. Specify the proposed submission date to indicate when the claims should begin submission.
8. Review and confirm the contract holder certification by checking the box that states your agreement with the accredited submitter aligns with the necessary specifications.
9. For signatures, ensure that the contract holder and submitter sign and date the form in the spaces provided. If more than one signatory is required, ensure all signatures are obtained.
10. Once all fields are completed, save changes, then download, print, or share the form as necessary before submitting.

Complete your application online to ensure a smooth electronic claims process.