835_electronic_consent

CAQH CORE - Electronic 835 Consent Form

*Required Field

Where would you like to receive rour electronic 835 from?

Provider Information


 

Provider Name

Doing Business as Name (DBA)

Provider Street Address 1

Provider Street Address 2

Provider City

Provider State

Provider Zip Code

Provider Country Code

Federal Tax Identification Number

NPI

Assigning Authority

Trading Partner ID

Provider License Number

License Issuer

Provider Taxonomy Code

Provider Contact/Agent Information


 

Provider Contact Name

Title

Provider Contact Phone Number

Phone Number Extension

Provider Contact FAX

Provider Contact Email Address

Provider Agent Name

Street Address 1

Street Address 2

City

State

Zip Code

Provider Agent Country Code

Provider Agent Contact Name

Title

Provider Agent Contact Phone Number

Phone Number Extension

Provider Agent Contact FAX

Provider Agent Contact Email Address

Federal Agency Information


Information required by the Veterans Administration

Federal Program Agency Name

FederalProgram Agency Identifier

Federal Agency Location Code

Electronic Remittance Advice Information


 

Preference for Aggregation of Remittance Data

Method of Retrieval

Electronic Remittance Advice Clearinghouse Information


 

Clearinghouse Name

Clearinghouse Contact Name

Electronic Remittance Advice Vendor Information


 

Vendor Name

Vendor Contact Name

Vendor Contact Phone Number

Vendor Contact Email Address

Vendor IP Address

Submission Information


 

Reason for Submission

Submission Date

Requested ERA Effective Date

Name of Person Submitting Enrollment

Electronic Signature of Person Submitting Enrollment