Get User Agreement Form

Filling out the User Agreement Form is a crucial step in using the eCMS system for submitting and tracking claim payments. This guide will help you understand each section of the form and provide step-by-step instructions to ensure you complete it accurately.

Follow the steps to successfully complete the User Agreement Form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in your federal tax identification number in the designated field. This is necessary for processing your claims.
3. Enter your printed name clearly in the provided space. Ensure that it matches your official identification documents.
4. Provide the name of your company in the corresponding field. This helps identify your organization among other users.
5. Specify your office suite or room number if applicable. This information aids in the identification and classification of your business location.
6. Complete the address section with your full mailing address, including city, state, and ZIP code.
7. Input your email address for communication purposes. Ensure it is accurate to receive notifications regarding your claims.
8. Enter your phone number so that you can be contacted if there are any clarifications needed regarding your submission.
9. Select your claims submission type by marking one or more of the provided options: Portal, EDI, or Both.
10. For security purposes, answer the verification questions regarding your mother's maiden name, place of birth, and favorite color.
11. Affirm your responsibility to notify the appropriate parties if your employment status changes by signing and dating the form.
12. Once completed, review all your entries for accuracy. Then save changes, download, print, or share the form as necessary.

Complete and submit your User Agreement Form online today to begin utilizing the eCMS system.