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ERA Enrollment Form

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ERA Enrollment

Provider Information
Provider Name *
Provider Identifiers Information
Provider Identifiers Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)	National Provider Identifier (NPI) *
Provider Contact Information
Provider Contact Name Contact *	Telephone Number *	Email Address *
Provider Agent Information
Provider Agent Name	Provider Agent Contact Name	Telephone Number
Email Address
Electronic Remittance Advice Information

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) Select one and fill in the number.*

Provider Tax Identification Number (TIN)

National Provider Identifier (NPI)

Method of Retrieval *

Electronic Remittance Advice Clearinghouse Information

Clearinghouse Name

Clearinghouse Contact Name

Telephone Number

Email Address

Submission Information

Reason For Submission *

New Enrollment

Change Enrollment

Cancel Enrollment

Authorized Signature *
Electronic Signature of Person Submitting Enrollment.

Requested ERA Effective Date *

This form complies with the CORE 382 ERA Enrollment Data Rule version 3.0.0 dated June 2012 mandated requirements.

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