PayerEDI Enrollment Forms

EDI Enrollment Forms

The forms are pre-populated with clearinghouse data and contain instruction sheets with paperwork submission information. 

The Paperwork Submission section on each instruction sheet provides information on what payers require online enrollment and what forms should be sent directly by you to the payers.

If you have any questions while completing these required EDI Enrollment forms, please contact HeW Enrollment staff at 877-565-5457.
 


Add/Update Providers

ERA Notification Form


Change of Vendor Form


Commercial Payer & Non-State Specific Enrollment Forms

All
 


State Specific Payer Enrollment Forms
 

A

Alabama
Alaska
Arizona
Arkansas

C

California
Colorado
Connecticut

D

Delaware

F

Florida

G

Georgia

H

Hawaii

I

Idaho
Illinois
Indiana
Iowa

K

Kansas
Kentucky

L

Louisiana

M

Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana

N

Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota

O

Ohio
Oklahoma
Oregon

P

Pennsylvania

R

Rhode Island

S

South Carolina
South Dakota

T

Tennessee
Texas

U

Utah

V

Vermont
Virginia

W

Washington DC
Washington (state)
West Virginia
Wisconsin
Wyoming