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Get GA Blue Cross Shield Electronic Funds Transfer Enrollment Form

Presentative. OR Electronic Remittance Advice (ERA) Support 3350 Peachtree Road EDI Services / GA014-0007 Atlanta, Ga 30326 Mail Forms to: Blue Cross Blue Shield of Georgia (888) 883-2720 (ERA only) Complete this form to request scheduling for implementation of EFT for the provider / faciilty indicated below. NOTE: A separate form is required for each Tax Identification Number & Location. Incomplete enrollment form will cause delay. Provider Name: ________________________________________.

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