Edi Enrollment Form Page 2

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Section C: Software Vendor, Billing Agent, or Clearinghouse Information
If Provider is Using a Software Vendor, Billing Agent, or Clearinghouse:
Select which one: Software Vendor
Billing Agent
Clearinghouse
Software Vendor/Billing Agent/Clearinghouse:
Name:
Contact Person:
Address:
City:
State:
Zip:
Phone:
Fax:
Email Address:
If Using a Software Vendor:
Software Version:
Section D: Transaction Type
Transaction Type: (check all that apply)
X12N 837I
X12N 837P
X12N 837D
X12N 270
  
Please Return Enrollment Form via (Email, Fax, or Mail) to AllyAlign EDI
Clearinghouse:
Fax: 877-386-1783
Email:

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