Get Availity Multi-payer Era Enrollment Form

Filling out the Availity Multi-Payer ERA Enrollment Form online is essential for providers to receive electronic remittance advice files. This guide offers clear and supportive instructions to help you complete the form effortlessly.

Follow the steps to successfully complete the enrollment form.

1. Click ‘Get Form’ button to access the enrollment form and begin filling it out. Ensure you gather all necessary information before proceeding.
2. In the Payer Information section, enter the name of the payer and the corresponding payer ID as indicated. You may add multiple payer entries as needed.
3. Next, complete the Receiver Information section by selecting the type of organization that will receive the ERA files: Provider, Clearinghouse, or Vendor. Provide the Receiver Name and the Availity Customer ID.
4. In the Provider Information section, fill in the complete legal name of your institution, your Federal Tax Identification Number (TIN) or Employer Identification Number (EIN), and your full address including street, city, state/province, and ZIP code.
5. Input your National Provider Identifier (NPI) number, ensuring this unique identifier is recorded accurately in the Provider Identifiers Information section.
6. Next, provide the contact information of a person who will handle ERA issues. Include their name, telephone number, and email address.
7. In the Electronic Remittance Advice Information section, indicate your preference for aggregation of remittance data by selecting the appropriate option and entering the corresponding TIN or NPI.
8. For Submission Information, indicate the reason for submission: New Enrollment, Change Enrollment, or Cancel Enrollment. Ensure the Authorized Signature is provided, acknowledging your authority to sign the form.
9. Complete the form by typing the printed name of the person submitting the enrollment and the date of submission.
10. Save the completed form. You can download, print, or share it as needed, or proceed to use the Send Form button to return it via email, fax, or mail.

Take action today to complete your enrollment by filling out the form online.