BILLING SERVICES: Change Healthcare Provider Complete Enrollment and Deactivation

It is important to read the following instructions to ensure your enrollment is processed correctly. Please ONLY use the following forms if you are a BILLING SERVICE COMPANY:

  • If you are an office wishing to ENROLL FOR THE FIRST TIME, complete the enrollment form “FIRST-TIME Enrollments” and the “ELECTRONIC PATIENT STATEMENTS” enrollment below
  • If you are an office wishing to ADD A NEW PROVIDER to an existing enrollment that has already been complete, complete the enrollment form “EXISTING Enrollments” below
  • If you wish to DEACTIVATE A PROVIDER, complete the enrollment form “DEACTIVATE Provider”

Please complete the following form for FIRST-TIME ENROLLMENTS:

Fields marked with an asterisk (*) are required.

Billing Service Name:*
Contact Name:
Contact Phone:*
Contact Email:*
Billing Service Tax #:*
Connect to :* ClientHost

Please provide your Vision Username:*
Please provider your Vision email address:*

Group / Provider Name: *

Street Address:
City:
State:
Zip Code:

Group Tax ID:*
Group NPI:*

Services Requested:* (Select all that apply) Claims, ERA & Real Time (Provider Inquiry)Professional Claims (1500 CMS)Institutional Claims (UB04)EFT

Multiple Databases?: YesNo

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Provider:
Credential:*
Tax ID: *
NPI: *

Additional Provider #2
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #3:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #4:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #5:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #6:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #7:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #8:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #9:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #10:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #11:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #12:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #13:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #14:
Provider:
Credential:*
Tax ID: *
NPI:

Additional Provider #15:
Provider:
Credential:*
Tax ID: *
NPI:

Electronic Patient Statements


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