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 and click add to save.

Section 3: Provider Contact Information
Section 4: Electronic Remittance Advice Information
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 Solutions, Inc., Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation and Quartz Health Insurance Corporation..
Authorized Signature

*Indicates a required field