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TBH-EDI_ERA
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Your email address

Subject

Product

Primary/Corporate Site Name:

Site Address Line 1

Site Address Line 2(optional)

City

State

Zip Code

Site Email Address(optional)

Phone Number(optional)

Fax Number

Location NPI(optional)

Do you have multiple locations with multiple NPIs?(optional)

NPI

Payor

Payor ID

Payor Type

Payor 2(optional)

Do you want to enroll for eligibility request 2?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 2(optional)

Payor Type 2(optional)

Payor 3(optional)

Do you want to enroll for eligibility request 3?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 3(optional)

Payor Type 3(optional)

Payor 4(optional)

Do you want to enroll for eligibility request 4?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 4(optional)

Payor Type 4(optional)

Payor 5(optional)

Do you want to enroll for eligibility request 5(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 5(optional)

Payor Type 5(optional)

Payor 6(optional)

Do you want to enroll for eligibility request 6?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 6(optional)

Payor Type 6(optional)

Payor 7(optional)

Do you want to enroll for eligibility request 7?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 7(optional)

Payor Type 7(optional)

Payor 8(optional)

Do you want to enroll for eligibility request 8?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 8(optional)

Payor Type 8(optional)

Payor 9(optional)

Do you want to enroll for eligibility request 9?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 9(optional)

Payor Type 9(optional)

Payor 10(optional)

Do you want to enroll for eligibility request 10?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 10(optional)

Payor Type 10(optional)

Payor 11(optional)

Do you want to enroll for eligibility request 11?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 11(optional)

Payor Type 11(optional)

Payor 12(optional)

Do you want to enroll for eligibility request 12?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 12(optional)

Payor Type 11(optional)

Payor 13(optional)

Do you want to enroll for eligibility request 13?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 13(optional)

Payor Type 13(optional)

Payor 14(optional)

Do you want to enroll for eligibility request 14?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 14(optional)

Payor Type 14(optional)

Payor 15(optional)

Do you want to enroll for eligibility request 15(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 15(optional)

Payor Type 15(optional)

Payor 16(optional)

Do you want to enroll for eligibility request 16(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 16(optional)

Payor Type 16(optional)

Payor 17(optional)

Do you want to enroll for eligibility request 17?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 17(optional)

Payor Type 17(optional)

Payor 18(optional)

Do you want to enroll for eligibility request 18?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 18(optional)

Payor Type 18(optional)

Payor 19(optional)

Do you want to enroll for eligibility request 19?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 19(optional)

Payor Type 19(optional)

Payor 20(optional)

Do you want to enroll for eligibility request 20?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 20(optional)

Payor Type 20(optional)

Payor 20(optional)

Payor ID 21(optional)

Do you want to enroll for eligibility request 21?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor Type 21(optional)

Payor 22(optional)

Payor ID 22(optional)

Do you want to enroll for eligibility request 22?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor Type 22(optional)

Payor 23(optional)

Do you want to enroll for eligibility request 23?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 23(optional)

Payor Type 23(optional)

Payor 24(optional)

Do you want to enroll for eligibility request 24?(optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 24(optional)

Payor Type 24(optional)

Payor 25(optional)

Do you want to enroll for eligibility request 25? (optional)

***This feature is for Fusion Web Clinic customers only***

Payor ID 25(optional)

Payor Type 25(optional)

Tax ID

Taxonomy number(optional)

Billing NPI ID

How many Individual NPI IDs(optional)

Max of 5

Individual NPI ID(optional)

Individual NPI ID 2(optional)

Individual NPI ID 3(optional)

Individual NPI ID 4(optional)

Individual NPI ID 5(optional)

Group NPI (optional)

Group ID or PTAN ID(optional)

Medicaid Provider ID(optional)

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

Attachments(optional)

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TBH-EDI_ERA