Customer Forms and Paperwork

Payer Forms and Agreements

 

Clearinghouses

RelayHealth Contract

RelayHealth Billing service sales order and contract form.

 

Medicare

Medicare EDI Enrollment Forms

Electronic Data Interchange Enrollment form for Medicare. Must be completed in order to file medicare claims electronically. Instructions for completing this form can be found at the CahabaGBA website

 

BCBS Alabama

Alabama BCBS EDI Sign-On Request for New (To FlexMedical) Submitters

Electronic Data Interchange request for client sign-on for BCBS AL.

 

Alabama BCBS EDI Sign-On Request for Existing FlexMedical Submitters

Electronic Data Interchange request for client sign-on for BCBS AL.

 

Alabama BCBS EDI Enrollment Request for 835 Remittance File

EDI enrollment form to receive electronic remittances through FlexMedical.

 

BCBS Georgia

Georgia BCBS EDI Trading Partner Agreement

Electronic Data Interchange Agreement for Georgia Blue Cross.

 

Georgia BCBS EDI Trading Partner Enrollment Form

Electronic Data Interchange Enrollment Form for Georgia Blue Cross.

 

Georgia BCBS EFT Enrollment Form

Electronic Funds Transfer Enrollment Form for Georgia Blue Cross. Note: This can only be filled out after sending in the EDI trading partner agreement and enrollment form and receiving approval from BC of GA on these two forms.

 

BCBS Mississippi

Mississippi BCBS Agreement & Enrollment Forms

Agreements and Enrollment forms for BCBS Mississippi.

 

BCBS Tennessee

Tennessee BCBS EDI Form

Electronic Provider Profile form for Blue Cross Tennessee.

 

FlexMedical Forms and Agreements

OCERIS Remote Access Authorization Form

Authorization form for clients when providing OCERIS with remote access to one of the computers at their office.

 

OCERIS Credit Card Authorization Form

Authorization form for clients when purchasing direct from OCERIS with a credit card, or when OCERIS orders products on behalf of a client using the client's credit card.

 

FlexMedical EULA

FlexMedical End User License Agreement.

 

Support Agreement

OCERIS Software Support Agreement.

 

Electronic Statements Sign-On Agreement

Sign-on agreement for utilizing OCERIS electronic statement service.

 

Employee Authorization Form

Form for detailing the name(s) of one or more people at the client site that will be capable of authorizing any charges outside the scope of normal monthly software support.

 

Patient Portal Agreement

Sign-on agreement for the FlexMedical Patient Portal.

External Resources

HIPAA-Related Code Lists

View HIPAA-Related Code Lists at the Washington Publishing Company. Of particular interest is the link entitled "Claim Adjustment Reason Codes".