EDI Claims Enrollment Form

IDENTIFICATION OF PROVIDER/TRADING PARTNER AND TRANSACTION INFORMATION

All Trading Partners, whether covered entities or business associates of covered entities, agree to abide by all HIPAA Privacy and Security requirements as they apply to communications with The Alliance.

Reminder: Prior to setting up Electronic Data Interchange (EDI) claims submission with the Alliance, a minimum of one paper claim must have been submitted to the Alliance so that a record for the office can be configured.

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