Office Ally New Payer Request Form

Office Ally submits electronically to a vast number of payers (our Payer Lists are available here), but in some cases there are payers that we have not yet connected to or certain lines of business that have not yet been added.

Please use this form to request a payer (or additional line of business for an existing payer) be added to our payer list. Complete the below fields and submit the form; once we receive this request, we will review the information and look into whether a connection with the requested payer is possible. Connection to the payer requested is not guaranteed.

Your information

Please provide your information so we can contact and follow up with you

Your request details

Payer Address

Select state

Requested Transactions

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