Emdeon Claims Provider Information Form Page 3
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3Smoky Mountain Center ‐ Electronic Connectivity Request
Please complete the following form and fax the form to Smoky Mountain Center, (828) 225‐2804 or email to
rob.minge@smokymountaincenter.com
A Connectivity Request form is required for each provider group.
PROVIDER NAME
NATIONAL PROVIDER ID
CONTACT NAME
TITLE
MAIL ADDRESS
CITY STATE ZIP CODE
PHONE NUMBER
FAX NUMBER
EMAIL ADDRESS (REQUIRED)
Estimate number of claims each month: __________________________________________________
VENDOR/CLEARINGHOUSE NAME
CONTACT NAME
TITLE
EMDEON
ENROLLMENT HELP DESK
MAIL ADDRESS CITY STATE ZIP CODE
3055 LEBANON PIKE
NASHVILLE
TN
37214
PHONE NUMBER
FAX NUMBER
EMAIL ADDRESS (REQUIRED)
615.231.4843
866.924.4634
_____________________________ _________________________________________ ________________________________________________
Date
Print Name/Title (Required)
Authorized Signature (Required)
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