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.
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.
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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