EDI 835 - Quartz Provider Forms

Authorization Agreement for Electronic Health Care Claim Payment / Advice (835)

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Section 1: Provider Information

Provider Name *

Street *

City *

State/Province *

Zip Code *

Section 2: Provider Identifiers Information

Identification Number *

Either Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN).

National Provider Identifier (NPI)

Provider may list multiple NPI #'s if they share the Federal Tax ID listed above. A separate implementation form needs to be completed for each unique Federal Tax ID. Enter each NPI number and click add to save.

Section 3: Provider Contact Information

Provider Contact Name *

Title *

Email Address *

Telephone Number *

Fax Number *

Section 4: Electronic Remittance Advice Information

Preference for Aggregation of Remittance Data *

Method of Retrieval

Section 5: Electronic Remittance Advice Clearinghouse Information

Clearinghouse Name *

Contact Name *

Phone Number *

Email Address *

Section 6: Electronic Remittance Advice Vendor Information

Vendor Name *

Contact Name *

Phone Number *

Email Address *

Section 7: Submission Information

Reason for Submission *

The information contained within this form will be applied to all applicable contracts with Quartz Health Solutions, Inc., Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation..

Authorized Signature

Signature of Person Submitting Enrollment *

Title of Person Submitting Enrollment *

By checking this box, I authorize the provider to enroll with ERA with Quartz Health Solutions, Inc., Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation.

Requested ERA Effective Date *

*Indicates a required field

Authorization Agreement for Electronic Health Care Claim Payment / Advice (835)

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