ENS Enrollment Form:
Complete this form.... we will contact you...
Contact Information
First Name -
X
Last Name -
X
Phone -
X
E-Mail -
X
Practice Information
Practice Name -
X
Tax-ID -
X
Street Address -
X
City -
X
State -
X
Zip Code -
X
Phone -
X
Fax -
X
Enter the required information for each provider in your practice
Provider #1
First Name -
X
MI
Last Name -
X
Social Sec # -
X
State Lic # -
X
Specialty -
X
UPin -
X
Provider #1 Pin Numbers
Payor
Individual Pin
Group Pin
Medicare
Medi-Cal
Blue Cross
Champus/Tricare
Railroad Medicare
Blue Shield
Other
Provider #2
(If Applicable)
First Name -
X
MI
Last Name -
X
Social Sec # -
X
State Lic # -
X
Specialty -
X
UPin -
X
Provider #2 Pin Numbers
Payor
Individual Pin
Group Pin
Medicare
Medi-Cal
Blue Cross
Champus/Tricare
Railroad Medicare
Blue Shield
Other
Provider #3
(If Applicable)
First Name -
X
MI
Last Name -
X
Social Sec # -
X
State Lic # -
X
Specialty -
X
UPin -
X
Provider #3 Pin Numbers
Payor
Individual Pin
Group Pin
Medicare
Medi-Cal
Blue Cross
Champus/Tricare
Railroad Medicare
Blue Shield
Other
Provider #4
(If Applicable)
First Name -
X
MI
Last Name -
X
Social Sec # -
X
State Lic # -
X
Specialty -
X
UPin -
X
Provider #4 Pin Numbers
Payor
Individual Pin
Group Pin
Medicare
Medi-Cal
Blue Cross
Champus/Tricare
Railroad Medicare
Blue Shield
Other
Other Information
Estimated Monthly Claim Volume -
X
Do currently submit electronic claims? -
X
Yes
No
Do you have an Internet connection? -
X
Yes
No
Do you want to access reports, eligibility, and ERA's over a secured Internet connection? -
X
Yes
No
Do you want to send patient statements electronically? -
X
Yes
No
