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Era Enrollment Form

Welcome to the DentaQuest Online Electronic Remittance Advice (ERA) Enrollment Request page. Please be sure to complete all of the required fields (marked with a star) and click on Submit before leaving this screen. Partial entries will not be saved.

The following needs to be completed before an ERA can be sent to your organization via a 5010 X12 835 transaction:

  • Complete the below enrollment form to receive the ERA.

Provider/Organization/Practice Identification

Organization/Practice Contact Person

Organization/Practice Address

We use an Agent for Processing Payments

Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Identifier)

Please choose aggregation type based on the identification used by your receiving bank on your bank account. If you are identified on your bank account by TIN, please choose TIN. If by NPI, please choose NPI. If you are identified by TIN, please do *not* choose NPI. The aggregation type must match your banking institution’s identification on your bank account.

Please enter the following information if you receive EDI transactions through a clearinghouse rather than directly. All fields below are required to complete your enrollment.

A Trading Partner (TP) Agreement is required before DentaQuest can begin to send remittance advices electronically

Please type your name, date, and the requested effective date for this enrollment below

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