Edi Enrollment Form
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1
2EDI Enrollment Form
New Enrollment
Update Enrollment
Select Payer:
Pruitt Health Premier
Missouri Medicare Advantage
Signature Advantage
Section A: Submitter Information
Submitter or Organization Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Provider NPI ID:
Tax ID:
Contact Information:
Technical Contact Information:
Name:
Name:
Title:
Title:
Email:
Email:
Phone:
Phone:
Section B: Submission Method
Individual Provider
Group Provider
Clearinghouse
Billing Agent
Vendor
If you are currently submitting electronic transactions directly to Exchange EDI please indicate
your Trading Partner ID:
If Clearinghouse, Billing Agent or Vendor:
Provider(s) Being Submitted (attach list if needed):
Provider Name:
Provider NPI(s):
Provider Tax ID:
If Individual Provider or Group Provider (attach list if needed):
Provider Name:
Provider NPI(s):
Provider Tax ID:
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Parent category: Business