Payer EDI Enrollment Forms

Some payers require pre-enrollment before permitting the provider to submit electronic claims to them. Typically payers such as Medicare, Medicaid, Blue Cross, and Blue Shield require pre-enrollment. Payers that require pre-enrollment are indicated on our Payer Lists (ENR column). As a service to our customers, Office Ally provides these agreements and forms below, pre-filled with Office Ally’s information where ever required. Below is a list of all Pre-Enrollment forms available (sorted by state).

Be sure to complete the form(s) as indicated on the Instructions Cover Page to ensure applications a
re not denied for incorrect/missing information.

All or Multiple States Payer Enrollment Forms Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas

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Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota

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Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington DC West Virginia Wisconsin Wyoming

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