Contact Us - Health Division

Please provide all appropriate information. This data is used to allow access to our secure B2B site with access to the CORE ERA and EFT Enrollment forms.

Please note all fields marked with an * are required.

Provider Information

Provider Name : *
(Includes individual medical provider, facility, clinic, etc.)
Tax ID (TIN) :  *
(Multiple TINs or NPIs require multiple Contact Us forms to enable multiple enrollment access.)
NPI ID : *
Entity Type Code :

(Entity Type Code 1 = Individual, 2 = Organization)

Provider Address

Street : *
Street (line 2) :
City : *
State : *
Zip : *

Provider Contact Information

Provider Contact Name : *
Telephone Number :  *
Telephone Extension :
Fax Number :
Email Address : *

Additional Information Required

Are you acting on behalf of provider? *

Only complete this section, if you will be completing the ERA EFT Enrollment forms on behalf of the provider
Vendor Name :
Contact Name :
Telephone Number :
Telephone Extension :
Fax Number :
Email Address :

ERA or ERA/EFT Enrollment, provide the Method of Retrieval

Method of Retrieval :

UHIN # (only IF "Method" is using UHIN)
Comments/Reason for contact (750 Characters)