Get Provider Electronic Payment And Remittance Enrollment Form

Completing the Provider Electronic Payment And Remittance Enrollment Form online is essential for ensuring efficient and timely payments. This guide will walk you through each step of the process, helping you understand the necessary components and requirements.

Follow the steps to complete your enrollment online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the provider information section. Enter your provider name, street address, city, state, and zip code. Ensure all details are accurate and complete to avoid delays.
3. In the provider identifiers information section, input your Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN), National Provider Identifier (NPI), NCPDP, and chain code if applicable. These identifiers are crucial for processing your enrollment.
4. Next, enter the provider contact information. Provide the name, phone number, fax number, and email of the designated contact person for your organization.
5. For the financial institution information, fill in the financial institution name, routing number, and the account number from which payments will be made. Indicate whether it is a checking account and link the account number to your provider identifier by entering the appropriate tax identification number.
6. Indicate the reason for submission by selecting one of the options: new enrollment, change enrollment, or cancel enrollment. It is important to mark the correct option to ensure proper handling of your request.
7. Finally, complete the authorized signature section by providing the electronic signature of the person submitting the enrollment along with their printed title. This signature confirms your authorization to enroll in electronic payments and remittance advice.
8. After filling out the form, save any changes and proceed to download or print a copy for your records. You may then mail the original signed form to the specified address, email it, or fax it according to the instructions provided.

Begin your enrollment process now by completing the Provider Electronic Payment And Remittance Enrollment Form online.