Era Enrollment Form

Welcome to the DentaQuest Online Electronic Remittance Advice (ERA) Enrollment Request page. Please be sure to complete all of the required fields (marked with a star) and click on Submit before leaving this screen. Partial entries will not be saved.

The following needs to be completed before an ERA can be sent to your organization via a 5010 X12 835 transaction:

Complete the below enrollment form to receive the ERA.

Please briefly explain your license request below

Provider/Organization/Practice Identification

Provider Name

Doing Business As Name (DBA)

National Provider Identifier(NPI)

Provider Federal Tax Identification Number (TIN)

Organization/Practice Contact Person

Provider Contact Name

Telephone Number

Email Address

Organization/Practice Address

Address 1 (Street Address or PO Box)

Address 2 (Suite number, etc)

City

Zip code

Yes No

Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Identifier)

Provider Tax Identification (TIN) National Provider Identifier (NPI)

Please enter the following information if you receive EDI transactions through a clearinghouse rather than directly. All fields below are required to complete your enrollment.

Clearinghouse Name

Clearinghouse Contact Name

Phone

I have a Trading Partner Agreement I do not have a Trading Partner Agreement

Please type your name, date, and the requested effective date for this enrollment below

Full Name

Submission Date

Requested Date

PREVENTISTRY PULSE

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