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

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

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

Street Address/P.O. Box

Provider Street Address 2

Apartment/Suite/Unit/Building/Floor

Provider City

Provider State

Provider Zip Code

5 digit zip code

Provider Country Code

ISO-3166-1 CountryCode

Federal Tax Identification Number

Also known as Employer Identification Number

NPI

10 digit National Provider Identifier

Assigning Authority

Trading Partner ID

Provider License Number

License Issuer

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 Name

First and Last Name

Title

Provider Contact Phone Number

###-###-####

Phone Number Extension

Provider Contact FAX

###-###-####

Provider Contact Email Address

Provider Agent Name

First and Last Name

Street Address 1

Street Address/P.O. Box

Street Address 2

Apartment/Suite/Unit/Building/Floor

City

State

Zip Code

5 digit zip code

Provider Agent Country Code

ISO-3166-1 CountryCode

Provider Agent Contact Name

First and Last name of a contact in agent office for handling EFT issues

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

Provider preference for grouping (bulking) claim payment remittance advice - must match preference for EFT payment

Method of Retrieval

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

Electronic Remittance Advice Clearinghouse Information


 

Clearinghouse Name

Official name of theprovider's clearinghouse

Clearinghouse Contact Name

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

Electronic Remittance Advice Vendor Information


 

Vendor Name

Official name of the provider's vendor

Vendor Contact Name

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

Vendor Contact Phone Number

###-###-####

Vendor Contact Email Address

Vendor IP Address

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

Submission Information


 

Reason for Submission

Submission Date

mm/dd/yyyy

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

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

Electronic Signature of Person Submitting Enrollment