Corporate

EDI Application

* Required

Date: 9/25/2018
Reason for Submission:*
Line of Business:*

Submitter Information

Input Submitter ID: *
If submitter ID number for 835 is left blank it will automatically default to 837 submitter ID requested unless you are currently setup for ERA/ERN. If requesting myCGS for ERA’s, please enter myCGS in the 835 field.
837 (for submitting claims):
835 (to receive ERA):
Type of Submitter:*
Submitter ID Entity Name:*
EDI Contact Person:*
Submitter Phone Number:* Ext:
Submitter E-Mail Address:*
Submitter Fax Number:
Submitter Address 1:*
Submitter Address2:
Submitter City:*
Submitter State:*
Submitter Zip:*

Software Vendor & Network Service Vendor (if a submitter ID# is being requested)

Name of Software Vendor:
Network Service Vendor:

Provider Information (You may enter up to 10 Providers.)

Group Practice/Provider Name: *
Provider Contact Name:
Provider E-Mail Address:*
Group Provider Number:*
Group NPI:*
Title:
Doing Business As Name (DBA):
Address 1:*
Address 2:
City:*
State:*
Zip:*

At the conclusion of the registration process you will be presented with a printable version of the Provider Authorization Form. This form must be signed by the Provider ONLY.

Add another Provider?

Would you like to order software? Yes No



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