University of Utah Health Plans - EDI Form
(835, 837 Trading Partner Setup and EFT Enrollment)
Provider Information
* Provider Name
* Street
* City
* State/Province
* Zip Code/Postal Code
* Country Code
Provider Identifier Information
* Tax ID (TIN) - Numbers Only
* National Provider Identifier (Billing NPI)
Trading Partner ID (Note: Required if only going through UHIN)
Provider Contact Information
* Provider Contact Name
Title
* Telephone Number
Telephone Number Extension
Fax Number
* E-mail Address
Provider Remittance Advice Clearinghouse Information
* Clearinghouse Name
Clearinghouse Contact Name
Telephone Number
Telephone Number Extension
E-mail Address
Financial Institution Information for EFT Enrollment Only (Note: To receive the ERA it must be linked to an EFT)
Financial Institution Name
Street
City
State/Province
Zip Code/Postal Code
Financial Institution Telephone Number
Telephone Number Extension
Financial Institution Routing Number
Type of Account at Financial Institution:
Checking
Provider's Account Number with Financial Institution
Submission Information
* Reason for Submission
New Enrollment
Change Enrollment
Cancel Enrollment
Requested EFT Start/Change/Cancel Date
Requested ERA Start/Change/Cancel Date
* Enter Name of Person Submitting Enrollment
* Title of Person Submitting Enrollment
Submission Date