Electronic Remittance / ERA / 835 Enrollment Forms

Some payers require pre-enrollment in order to activate Electronic Remittance Advice (ERA/835). Payers that require pre-enrollment for ERA are indicated on our Payer Lists. 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.