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Office Information

Customer ID*

Contact Name*

Office Phone*

Contact Email Address*

NOTE: Please be aware that we cannot guarantee an EDI connection due to
Payer discretion, however we will do everything possible to fulfill your request.

Type of Dental Connection asking for (please select all applicable)

Claims

Attachments

Eligibility

eEOB (835/ERA)

Payer Information

Payer Name

Payer Phone Number

Payer Contact Name

Payer Address

Payer City

Payer State

Payer Zip Code

Notes (if applicable)

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