Get Electronic Data Interchange (edi) Provider Change Form - Emdeon

Filling out the Electronic Data Interchange (EDI) Provider Change Form - Emdeon online is a crucial step in updating your provider information accurately. This guide will walk you through each section of the form, ensuring that you have the necessary guidance to complete it effectively.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to access the Electronic Data Interchange (EDI) Provider Change Form - Emdeon and open it in the editor.
2. Enter the provider organization details. Fill in the practice or facility name, provider name, tax ID, client ID, and site ID including the address, city/state, and zip code.
3. Provide contact information by entering the contact person's name and their email address. Ensure accuracy so that any necessary correspondence can reach the correct individual.
4. Input the telephone and fax numbers of the provider organization. This information is essential for communication purposes.
5. Complete the vendor information section. Enter the name of the Emdeon certified vendor used for submitting files, along with the vendor submitter ID and division ID.
6. Fill out the payer details as requested. Include the payer ID along with any relevant group or individual provider IDs.
7. Provide the NPI ID required for your enrollment and specify where you would like Emdeon claim confirmations to be sent.
8. Read and comply with any special instructions provided, ensuring you have all necessary signatures where applicable. Stamped signatures or photocopies are acceptable.
9. Review the completed form for accuracy. Verify that all required fields marked with an asterisk (*) are filled out correctly.
10. Once completed, save your changes, download, print the form, and ensure the signature is added where indicated. Finally, submit the form to the provided fax number or email address.

Complete the Electronic Data Interchange (EDI) Provider Change Form - Emdeon online accurately and efficiently.