Documents
PROTOCOLS
| PROTOCOLS | DESCRIPTION | DOCUMENT |
|---|---|---|
Medicare Part B | Puerto Rico Submitters | |
Medicare Part B | U.S. Virgin Island Submitters | |
Medicare Part A | EDI Enrollment Form (MA) | |
Medicare Part A VI | U.S. Virgin Island Submitters | |
CIGNA | Dental EFT Authorization | |
AETNA | AETNA ERA-835 | |
HUMANA | ERA-835 (Hawaii, PR & VI) | |
CEDI-DME | CEDI Enrollment Agreement Instructions | |
MAPFRE | ACH-Electronic Payments | |
Delta Dental | Secure EDI ERA Enrollment | |
Molina Healthcare | Molina ERA Enrollment | |
RR Medicare | Agreement | |
Humana Medicare | Application process |
FORMS
| FORMS | DESCRIPTION | DOCUMENT |
|---|---|---|
Installation Form | English | |
Formulario de Instalación | Español | |
Account Configuration Form | English | |
Formulario de configuración de la cuenta | Español | |
Accounting – Direct Debit Form | English | |
SecureEMR - Formulario para Cambios y Configuraciones | English | |
SecureEMR - Formulario para la Creación de Nuevo Usuario | Español | |
Authorization to Use/Disclose Protected Health Information | English |
