EDI Sign Up

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EDI


	EDI Sign Up


	EDI

Complete the EDI sign-up sheet today. You can either download the form and fax or mail to us, or submit it online. Once you complete this form, PPOM or Sloans Lake will contact you to confirm the vendors you are using, answer any questions, and set your practice up for electronic claims transmission.

To complete this form, you may need to review the trading partner choices from the Trading Partners pages.

1 a. *Will you use a billing service?	YesNo
b. If yes, which one?
2 a. *Will you use software and transmit EDI yourself?	YesNo
b. If yes, which one?
c. *If yes, would you like a direct link with PPOM/Sloans Lake?	YesNo
3 a. *Do you plan to use a clearinghouse?	YesNo
b. If yes, which one?
4. *NPI Identification Number:
5. *Federal Tax Identification Number:
6. *Physician Clinic Names (as they would appear):
7. *Payment To:
8. *Phone Number:
9. *Contact Name:
10. *Email Address: