835 Healthcare Claim Payment/Advice Request Form General Completion Instructions. SECTION A TYPE OF REQUEST (Please choose only one)

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Ferdinand Strickland
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1 835 Healthcare Claim Payment/Advice Request Form General Completion Instructions Purpose: The 835 Healthcare Claim Payment/Advice Request Form is designed for entities wanting to sign up to receive an 835 version 4010A1 Healthcare Claim Payment/Advice electronic transaction. This form may also be used by entities to change (Add/Remove a provider) or modify existing demographic information. SECTION A TYPE OF REQUEST (Please choose only one) Initial Request - Check this box to sign up to receive an 835 Healthcare Claim Payment/Advice. Change - Check this box to: o Modify existing sender/receiver information o Add or delete a provider SECTION B ORGANIZATION/SENDER INFORMATION Complete the Organization/Sender information appropriately. All fields are required with the exception of the Sender Number field. The Sender Number field should be the entity that will be retrieving the remittance from Availity and should only be completed if applicable. SECTION C VENDOR INFORMATION (Example: Company that supports ERA Software, Billing Service, and Clearinghouse) Complete the Vendor information appropriately. This section is for the vendor that supports your electronic remittance advice software. The following fields are required: Vendor Name Contact Name Telephone Number The remaining fields should only be completed if applicable. SECTION D: WHERE DO YOU WANT YOUR ELECTRONIC REMITS SENT? Select A if you would like your electronic remits sent to your Availity Mailbox directly (where you retrieve your other files on Availity) Select B if you would like your electronic remits to be sent to your vendor, billing service, or clearinghouse and not directly to you.

2 SECTION E PROVIDER/SUPPLIER/PA GROUP/ FACILITY NUMBER(S) List all individual providers (physician or facility), their Federal Tax ID, and their Blue Cross Blue Shield of Florida assigned provider number for which you would like to receive Remittance Notification. SECTION F AVAILITY INFORMATION All 835 version 4010A1 Healthcare Remittance Payment/Advice receivers must be registered with Availity prior to submitting this request form to Blue Cross Blue Shield of Florida. Check yes if registered with Availity. To Register with Availity, please call Availity or visit their website at Completed Forms Return completed forms to the address indicated on page 6 of the 835 Healthcare Claim Payment/Advice request form or fax them to Attention: Sender Setup.

SECTION F AVAILITY INFORMATION All 835 version 4010A1 Healthcare Remittance Payment/Advice receivers must be registered with Availity prior to submitting this request form to Blue Cross Blue Shield

3 835 HEALTHCARE CLAIM PAYMENT/ADVICE REQUEST FORM SECTION A: TYPE OF REQUEST Initial Request Change (Add/Remove Provider) SECTION B: ORGANIZATION/SENDER INFORMATION Organization/Sender Name: Organization Address: Contact Name: Telephone Number: Fax Number: Sender Number (if applicable) SECTION C: VENDOR INFORMATION (Example: Company that supports ERA Software, Billing Service, and Clearinghouse) Vendor Name: Address: Contact Name: Telephone Number: Fax Number: Vendor Number (if applicable) SECTION D: WHERE DO YOU WANT YOUR ELECTRONIC REMITS SENT? A -Your Availity Mailbox B - Vendor, Billing Service, Clearinghouse Availity Mailbox

INFORMATION (Example: Company that supports ERA Software, Billing Service, and Clearinghouse) Vendor Name: Address: Contact Name: Telephone Number: Fax

4 SECTION E: PROVIDER/SUPPLIER/PA GROUP/ FACILITY NUMBER(S) List all individual providers (physician or facility), their Federal Tax ID, and their Blue Cross Blue Shield of Florida assigned provider number for which you would like to receive Remittance Notifications on their behalf. Professional If you receive reimbursement for multiple tax ids, please list them here. If there is a preference to receiving the 835 for one tax id, please list the tax id in 1 st row. Provider Name / PA Group Name BCBSFL Provider No. Federal Tax ID For Inter Use Only

their behalf. Professional If you receive reimbursement for multiple tax ids, please list them here.

5 Institutional If you receive reimbursement for multiple tax ids, please list them here. If there is a preference to receiving the 835 for one tax id, please list the tax id in 1 st row. Facility Name BCBSFL Facility No. Federal Tax ID For Inter Use Only

If there is a preference to receiving the 835 for one tax id,

6 SECTION F: AVAILITY INFORMATION All Electronic Remittance Advice (ERA) receivers must be registered with Availity. In order to receive an 835, you must be registered with Availity prior to submitting this request to Blue Cross Blue Shield of Florida. Please contact Availity or visit their website at RETURN COMPLETED FORMS TO: BCBSF 4800 Deerwood Campus Parkway Jacksonville, FL Attn: DCC2-5 - Sender Setup OR FAX TO: Attention: Sender Setup FOR INTERNAL USE ONLY Provider File Update: By: TPD SCODE: GENKEY:

Please contact 1-800-Availity or visit their website at www.availity.com.

7 To: Availity, L.L.C. From [Provider]: Tax ID #: Subject: Availity Business Associate Provider Access Delegation Form Date: I am a Physician, Hospital-Based Physician, or Physician Group currently under contract with [Business Associate] having offices at for medical billing and/or other claims related services. I do hereby authorize [Business Associate] access to claims and other related information for my patients through their use of the Availity Gateway. I do hereby affirm that all of the necessary consents have been obtained from such patients to grant access to their claims and other related information to [Business Associate]. Upon the termination of services provided by [Business Associate] to my practice, I understand it is my responsibility to notify Availity through the execution of the Availity Business Associate Provider Access Termination Form, which can be provided by the Business Associate currently performing transactions on my behalf or accessed online at Physician, Hospital-Based Physician, or Physician Group Name Title Signature Date Availity Business Associate Provider Access Delegation Form

[Business Associate] having offices at for medical billing and/or other claims related services.

BCBS Florida 835 (BS590)

BCBS Florida 835 (BS590) Submitter ID: H3493 Payer ID: BS590 Form Instructions: Section A: To be completed by. If you are changing vendors, a letter of intent is to be included with the enrollment form.