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Forms Information about PDF Files

Electronic Remittance (ERA) Form

Use this form to:

Receive the HIPAA compliant electronic remittance (835 transaction).  This format is designed for auto-posting through a practice management software or for sites using software to translate the electronic file into a readable format.

New Trading Partner Enrollment Form

Use this form to:

  • Apply for a new trading partner number to begin submitting claims directly to ASK.

Application for New Trading Partner Number and Claim (837) Enrollment

NOTE:  Providers who will be sending claims through a clearinghouse should check with the enrollment department of their clearinghouse.

Contact Person Updates

The following options are available to add additional contact names, or to change the contact person:  Please include the Trading Partner number on the request.

Fax – Request must be made on company letterhead & signed by current contact or office manager.

Email – Email address must contain the organization name.

Change of Information Forms

This Change of Information Form is only used for a change in Trading Partner information (ie: address, contact, email) and Vendor changes. This form is no longer used to add additional NPI numbers or 837 and 27X Transactions.

Web-based change of information form

Secure Question Submission Form

If you have questions, please contact us.

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