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COVID-19

Electronic Remittance Advice Enrollment Form

 Required Fields

PAYOR INFORMATION

Indicate the payor (one or both below) for this Electronic Remittance Advice (ERA) submission:

PROVIDER INFORMATION

PROVIDER IDENTIFIERS INFORMATION

PROVIDER CONTACT INFORMATION

ELECTRONIC REMITTANCE ADVICE INFORMATION

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)

Method of Retrieval

ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION

ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION

SUBMISSION INFORMATION

Reason for Submission

Authorized Signature

(enter your name here)