Payer Enrollment Forms

Some payers require pre-enrollment before permitting the provider to/ submit electronic claims to them.  Typically payers such as Medicare, Medicaid, Blue Cross, and Blue Shield require pre-enrollment.  Payers that require pre-enrollment are indicated on our Payer Lists (PreEnr column).  As a service to our customers, Office Ally provides these agreements and forms below, pre-filled with Office Ally’s information whereever required.  Below is a list of all Pre-Enrollment forms available (sorted by state and payer). 

Be sure to complete the form(s) as indicated on the Instructions Cover Page to ensure applications are not denied for incorrect/missing information.

ALL or Multiple States Payer Enrollment Forms 

Payer Enrollment Forms for State Specific Payers:
AL
| AK | AZ | AR | CA | CO | CT | DE | FL | GA | HI | ID | IL | IN | IA | KS | KY | LA | ME | MD
MA
| MI | MN | MS | MO | MT | NE | NV | NH | NJ | NM | NY | NC | ND | OH | OK | OR | PA | RI | SC
SD
| TN | TX | UT | VT | VA | WA | DC | WV | WI | WY

Electronic Remittance / ERA / 835 Enrollment Forms

 

All or Multiple States Payer Enrollment Forms

 

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Back to top Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

Back to top New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Virgin Islands              

Washington

Washington DC

West Virginia

Wisconsin

Wyoming

Back to top Electronic Remittance / ERA / 835 Enrollment Forms  

 

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