Fillable 835 Health Care Claim (Page 3 of 3) in pdf

835 Health Care Claim Page 3

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Exhibit A

835 Registration 4010A1

6. Method of Electronic Access (check one)

IVANS (Please refer to the IVANS section of our website at: )

VisionShare (Please refer to the VisionShare section of our website at: )

Dial-up (If dial-up, check desired protocol below.)

Zmodem

Ymodem

Kermit

Other ________________________

7. Delivery of Remittance (check one)

Deliver Remit to:

Billing Service

Clearinghouse

Provider (Self)

Receiver Name:

Electronic Network Systems, Inc (ENS)

8. Select all that apply. Fill in the blank with the appropriate clinic or billing provider number. Note: Separate 835

registration forms for Instituti onal and Professional LOB are required if requesting BOTH Institutional and

Professional ERA transactions.

Professional Lines of Business

Medicare B (check only one state)

WY.......... Billing Provider #: _______________________

Blue Shield (check only one state)

WY.............................................. Billing Provider #: _______________________

North Dakota Vision Services, Inc

ND ............... Clinic #: ________________________________

Dental Service Corporation of North Dakota (DSC)

ND............................................................. Clinic #: ________________________________

Institutional Lines of Business

Medicare A (check only one state)

WA .................. Billing Provider #: _______________________

Blue Cross (check only one state)

WY………………………………Clinic #: _________________________________

ORIGINAL SIGNATURE

n appropriate original ink signature (refer to the Form Completion Instructions) is required for this document. Blue

ink is preferred. The form with an original ink signature must be mailed to EDISS to avoid any interruptions

in your ability to exchange data with EDISS.

I am authorized to sign this document on behalf of the provider/facility, and I authorize the set-up

noted above for the 835 Health Care Claim Payment/Advice transaction.

Signature: ____________________________________________

Print name: ___________________________________________

Title: ________________________________________________

Date: ________/________/________

Page 3 of 3

Last update on 07/15/04

835 Health Care Claim Page 3

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