Emdeon Claims Provider Information Form
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Complete Emdeon Claims Provider Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1
2
313010
PAYER ID:
SUBMITTER ID:
Emdeon
Claims
Provider Information Form
*This form is to ensure accuracy in updating the appropriate account
1
Provider Organization
Practice/ Facility
Provider Name
Name
Site ID
Client ID
Tax ID
Zip
Address
City/State
Code
Contact Name
E-mail Address
Telephone
Fax
2
Vendor
(
Emdeon certified vendor used to submit files to Emdeon)
Vendor Submitter
Vendor Name
Division ID
ID
Contact Name
E-mail Address
3
Payer
13010 SMOKY MOUNTAIN CENTER
Payer ID
Group ID
Individual Provider ID
NPI ID
4
Confirmations
Send Emdeon Claim Confirmations To:
Special Instructions:
All Payer Registration forms must contain signatures when applicable, stamped signatures or
photocopies are accepted.
SUBMIT COMPLETED FORM TO:
Fax: (615) 231-4843
Email:
12/09/13
EMDEON REVISION FORM DATE:
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Parent category: Legal