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Fillable Emdeon Claims Provider Information Form

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PAYER ID: 93093 SUBMITTER ID: Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Provider Name Client ID City/State Site ID Zip Code Practice/ Facility Name Tax ID Address Contact Name E-mail Address Telephone Fax 2 Vendor (Emdeon certified vendor used to submit files to Emdeon) Vendor Submitter ID Division ID Vendor Name Contact Name E-mail Address 3 Payer Payer ID Group ID 93093 OREGON LIFEWISE HEALTH More

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OREGON 4010X098A1 Emdeon SUBMITTER E-mail LIFEWISE EDI Payerregistrationemdeon EDIlifewisehealth LWHP batchenrollmentEmdeon NPI Donelson HIPAA TN ext Bldg IDs PAYER Confirmations Clearinghouse photocopies applicable providers submitting Enrollment Demogra

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