Electronic Remittance / ERA / 835 Enrollment Forms


Some payers require enrollment in order to activate Electronic Remittance Advice (ERA/835). Payers that require enrollment for ERA are indicated on our Payer List. As a service to our customers, Office Ally provides these forms below, pre-filled with Office Ally’s information where ever required. Below is a list of all electronic remittance advice (ERA/835) forms available (sorted alphabetically).

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


 

Payer ERA Enrollment Forms (A-Z)

Click here to view Non-ERA Payer Enrollment Forms
Click here to view access the ERA Delivery Change Form


#1-9 A

B

 
C

 
D E F

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G H I J K L M

 
 
N O

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P

Q R S

T U

V W Y

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