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835_electronic_consent

CAQH CORE - Electronic 835 Consent Form

*Required Field

*Required Field

Where would you like to receive rour electronic 835 from?

Where would you like to receive rour electronic 835 from? null

Provider Information

 

Provider Information

 

Provider Name

Provider Name Complete legal name of institution, corporate entity, practice or individual provider null

Doing Business as Name (DBA)

Doing Business as Name (DBA) A legal term used in the United States meaning that the trade name, or fictitious businessname under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it

Provider Street Address 1

Provider Street Address 1 Street Address/P.O. Box null

Provider Street Address 2

Provider Street Address 2 Apartment/Suite/Unit/Building/Floor

Provider City

Provider City null

Provider State

Provider State null

Provider Zip Code

Provider Zip Code 5 digit zip code null

Provider Country Code

Provider Country Code ISO-3166-1 CountryCode

Federal Tax Identification Number

Federal Tax Identification Number Also known as Employer Identification Number null

NPI

NPI 10 digit National Provider Identifier null

Assigning Authority

Assigning Authority

Trading Partner ID

Trading Partner ID

Provider License Number

Provider License Number

License Issuer

License Issuer

Provider Taxonomy Code

Provider Taxonomy Code A uniquealphanumeric code, ten characters in length. The code set is structuredinto three distinct “Levels” including provider Type, Classification andArea of Specialization

Provider Contact/Agent Information

 

Provider Contact/Agent Information

 

Provider Contact Name

Provider Contact Name First and Last Name null

Title

Title

Provider Contact Phone Number

Provider Contact Phone Number ###-###-#### null

Phone Number Extension

Phone Number Extension

Provider Contact FAX

Provider Contact FAX ###-###-####

Provider Contact Email Address

Provider Contact Email Address null

Provider Agent Name

Provider Agent Name First and Last Name null

Street Address 1

Street Address 1 Street Address/P.O. Box null

Street Address 2

Street Address 2 Apartment/Suite/Unit/Building/Floor

City

City null

State

State null

Zip Code

Zip Code 5 digit zip code null

Provider Agent Country Code

Provider Agent Country Code ISO-3166-1 CountryCode

Provider Agent Contact Name

Provider Agent Contact Name First and Last name of a contact in agent office for handling EFT issues null

Title

Title

Provider Agent Contact Phone Number

Provider Agent Contact Phone Number ###-###-#### null

Phone Number Extension

Phone Number Extension

Provider Agent Contact FAX

Provider Agent Contact FAX ###-###-####

Provider Agent Contact Email Address

Provider Agent Contact Email Address null

Federal Agency Information

Information required by the Veterans Administration

Federal Agency Information

Information required by the Veterans Administration

Federal Program Agency Name

Federal Program Agency Name

FederalProgram Agency Identifier

FederalProgram Agency Identifier

Federal Agency Location Code

Federal Agency Location Code

Electronic Remittance Advice Information

 

Electronic Remittance Advice Information

 

Preference for Aggregation of Remittance Data

Preference for Aggregation of Remittance Data Provider preference for grouping (bulking) claim payment remittance advice - must match preference for EFT payment null

Method of Retrieval

Method of Retrieval The method in which the provider will receive ERA from the health plan (e.g., download from healthplan website, clearinghouse, etc.) null

Electronic Remittance Advice Clearinghouse Information

 

Electronic Remittance Advice Clearinghouse Information

 

Clearinghouse Name

Clearinghouse Name Official name of theprovider's clearinghouse null

Clearinghouse Contact Name

Clearinghouse Contact Name First and Last name of contact in clearinghouse office for handling ERA issues

Electronic Remittance Advice Vendor Information

 

Electronic Remittance Advice Vendor Information

 

Vendor Name

Vendor Name Official name of the provider's vendor null

Vendor Contact Name

Vendor Contact Name First and Last name of a contact in vendor office for handling ERA issues

Vendor Contact Phone Number

Vendor Contact Phone Number ###-###-####

Vendor Contact Email Address

Vendor Contact Email Address

Vendor IP Address

Vendor IP Address The Internet Protocol(IP) Address by which communication is allowed between the Vendor and the health plan null

Submission Information

 

Submission Information

 

Reason for Submission

Reason for Submission null

Submission Date

S
M
T
W
T
F
S
Submission Date mm/dd/yyyy

Requested ERA Effective Date

S
M
T
W
T
F
S
Requested ERA Effective Date mm/dd/yyyy - Date the provider wishes to begin ERA; per Phase III CORE Health Care Claim Payment/Advice(835) Infrastructure Rule Version 3.0.0: There may be a dual delivery period depending on whether the entity has such an agreement with its trading partner

Name of Person Submitting Enrollment

Name of Person Submitting Enrollment First and Last name of the person signing the form; may be used with electronic and paper-based manual enrollment null

Electronic Signature of Person Submitting Enrollment

Electronic Signature of Person Submitting Enrollment null

 

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