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

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Section 1: Provider Information

Section 2: Provider Identifiers Information

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

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 on its own line.

Section 3: Provider Contact Information

Section 4: Electronic Remittance Advice Information

e.g. SFTP via Unity SFTP server connection

Section 5: Electronic Remittance Advice Clearinghouse Information

Section 6: Electronic Remittance Advice Vendor Information

Section 7: Submission Information

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

Authorized Signature

*Indicates a required field