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Get Office Ally 835 Enrollment Request 2020-2024

Ber Employer Identification Number (EIN): National Provider Identifier (NPI): PROVIDER CONTACT INFORMATION Contact Name: Telephone Number/Extension: Email Address: Fax Number: ELECTRONIC REMITTANCE ADVICE INFORMATION (CHECK ONLY ONE) Preference for Aggregation of Remittance Data: (i.e. Account Number Linkage to Provider Identifier). Note: Provider Preference for grouping (bulking) claim payment advice. Must match preference for EFT payment (i.e. Billing Provider). Choose and fill in only o.

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