Get Option Selection Form

The Option Selection Form is an essential document used by providers to manage their electronic data interchange services. This guide will provide you with step-by-step instructions on how to effectively complete the form online.

Follow the steps to successfully complete the Option Selection Form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Select the appropriate option by checking one of the following: 'Begin Registration,' 'Terminate Registration,' or 'Change Options.' Make sure you are checking the option that applies to your situation.
3. Enter your provider name or business name in the designated field.
4. Provide your National Provider Identifier (NPI) in the allotted space to ensure proper identification.
5. Fill out your complete address, including city, state, and zip code, in the respective fields.
6. Input your contact name and phone number for any follow-up communication related to the submission.
7. Indicate your software or practice management system as this assists in processing your electronic submissions.
8. Identify the input from and return output options relevant to your office in the provided fields. Select from the choices like Service Office (SO), Billing Office (BO), or Clearing House (CH) as necessary.
9. Answer the questions regarding electronic submissions of Claims, TARs, and Adjustments by circling 'YES' or 'NO' as applicable.
10. Select the return output options available by circling the relevant documents such as EDI Document, Electronic RTDs, or others that pertain to your operations.
11. Provide your authorized applicant's original signature, confirming that the information entered is accurate.
12. After confirming all fields are complete and accurate, save your changes, download, print, or share the form as necessary.

Complete your documents online and ensure your submissions are processed efficiently.