Provider Registration
Contact Information
TP Name:
Tax Id:
Org Type:
-- Type --
Billing Agency
Clearing House
Clinic
Group Practice
Hospital
Physician Office
Address 1:
Address 2:
City:
State:
Zip:
Contact Information
First Name:
Last Name:
Job Title:
Phone Number:
Email:
Electronic Information
Authorization 278
Claim Status 276/277
Claims 837 Dental
Claims 837 HCFA
Claims 837 UB-92
DDE Claims 837 HCFA
DDE Claims 837 UB-92
EFT
Eligibility 270/271
Enrollment 834
Premium 820
Proprietary Formats
Remittance 835
General Information
What clearinghouses do you currently interface?
ACS
Emdeon
ENS
Gateway EDI
MedAvant
Misys
Office Ally
PerSe
Post & Track
SSI Group
THIN
Other clearinghouses not listed above?
What is your Practice Management Software?
Please list top 5 payors you interface with?
Payor
Volume
Would you like to be contacted for an AdminisTEP demo?
Yes Please
No Thank You
