normal

Office Information

Customer ID*

Contact Name*

Office Phone*

Contact Email Address*

NOTE: Please be aware that we cannot guarantee an EDI connection due to
Payor discretion, however we will do everything possible to fulfill your request.

Type of Dental Connection asking for (please select all applicable)

Claims

Attachments

Eligibility

eEOB (835/ERA)

Payor Information

Payor Name

Payor Phone Number

Payor Contact Name

Payor Address

Payor City

Payor State

Payor Zip Code

Notes (if applicable)