Transcription of Electronic Remittance Advice (ERA) Enrollment Form
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Electronic Remittance Advice (ERA) Enrollment Form
PROVIDER INFORMATIONP rovider Name:Provider Address:Street:City:State/Province:Zip Code/Postal Code:PROVIDER IDENTIFIERS INFORMATIONP rovider Identifiers:Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):National Provider Identifier (NPI): (Billing NPI must be 10 digits)PROVIDER CONTACT INFORMATIONP rovider Contact Name:Title:Telephone Number:Telephone Number Extension:Email Address: (Required, if applicable)Fax Number: Electronic Remittance Advice INFORMATIONP reference for Aggregation of Remittance Data: (Select one) c Provider Tax Identification Number (TIN) c National Provider Identifier (NPI) Electronic Remittance Advice CLEARINGHOUSE INFORMATIONC learinghouse Name: Electronic Remittance Advice VENDOR INFORMATIONV endor Name:SUBMISSION INFORMATIONR eason for Submission: (Select one) c New Enrollment c Change Enrollment c Cancel EnrollmentAuth
(ERA Enrollment Form, Page 2) OTHER DATA In addition to the maximum data elements required for ERA enrollment, BCBSIL will need the following information to finalize your request:
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