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Authorization for 835 ERA Enrollment Form

*required fields

  • DEG 8 Electronic Remittance Advice Clearing House Information.
  • DEG 10 Submission Information.
ex.(4124545112) x ex.(9021)
  • DEG 1 Provider Information
  • DEG 2 Provider Identifiers Information
  • DEG 3 Provider Contact Information
  • DEG 7 Electronic Remittance Advice Information