Transcription of Electronic Remittance Advice Agreement Form …
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Electronic Remittance Advice Agreement Form …
Revised 03/14 Louisiana Medicaid Program LOUISIANA MEDICAID Electronic Remittance Advice (ERA) AUTHORIZATION Agreement (Form is subject to change without notice) Revised 03/14 GENERAL INFORMATION FOR THE Electronic Remittance Advice (ERA) AUTHORIZATION Agreement Complete this form if you are requesting receipt of the Electronic Remittance Advice (HIPAA v5010 221A1 835 transaction) for the first time or wish to change the submitter or clearinghouse authorized to receive the 835 on your behalf. Individual providers: Individual providers must sign their own forms. Original signatures only; no stamps or copied signatures will be accepted. (Blue or colored ink preferred not black ink). If the individual provider is doing group billing only, then an ERA form should not be completed for the individual. Instead, an ERA form should be submitted (or already on file) only for the business or entity which the individual is linked to. Business/Entity providers: Only an authorized representative may sign this form.
(Revised 01/14) LOUISIANA MEDICAID ELECTRONIC REMITTANCE ADVICE (ERA) AUTHORIZATION AGREEMENT INSTRUCTIONS 1. Provider Name Complete legal name of institution, corporate entity, practice or individual provider.
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