Unity Provider Forms
Electronic Health Care Claim Payment / Advice (835)

 

Authorization Agreement For Electronic Health Care Claim Payment / Advice (835)


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Section 1: Provider Information





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Section 2: Provider Identifiers Information


Either Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

Provider may list multiple NPI #’s if they share the Federal Tax ID listed above.
A separate Implementation form needs to be completed for each unique Federal Tax ID.
Enter each NPI number on its own line.


Section 3: Provider Contact Information








Section 4: Electronic Remittance Advice Information



e.g. SFTP via Unity SFTP server connection


Section 5: Electronic Remittance Advice Clearinghouse Information







Section 6: Electronic Remittance Advice Vendor Information







Section 7: Submission Information






The information contained within this form will be applied to all applicable contracts with Unity Health Plans Insurance Corporation, Quartz Health Solutions, Inc., Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota, and Physicians Plus Insurance Corporation.



Authorized Signature


By checking this box, I authorize the provider to enroll with ERA with Quartz Health Solutions, Inc.,
Unity Health Plans Insurance Corporation, Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota
and Physicians Plus Insurance Corporation.
 






* Indicates a required field.