Electronic Remit Request

Please complete the form below for ERA requests.

Please note: Any missing or incorrect information could delay processing of your request. A claims enrollment team member will contact you regarding any additional information required to process your request.

Once the ERA form has been submitted or the online enrollment completed, ERA requests have an average 2-4 week processing time, depending on payer requirements and response time.

To ensure enrollment information is sent for the correct payer, please include the payer ID.

Facility Information

Facility Name: *

MatrixCare Client ID: *


Facility NPI: *

Facility Tax ID: *

Is this tax ID shared with other facilities, hospitals or care-settings?: *

Enrollment Contact: *

Enrollment Contact Title: *

Enrollment Contact Email: *

Enrollment Contact Phone: *

Enrollment Contact Fax: *

Payer Information

Payer Type:

Claims Management Payer Name: *

Provider ID/PTAN: *

Bill Through State:

EFT Setup?:

Succcessful Claim with Payer?:

Form Type:

State Specific Managed Medicaid Program:

Authorized Signer Information

Authorized Signer's Name: *

Authorized Signer's Title: *

Authorized Signer's Email: *

Authorized Signer Phone: *

Authorized Signer Fax: *