Facility or Practice Information Name: Tax Id: Org Type: -- Type -- Billing Agency Clearing House Clinic Group Practice Home Care Services Hospital Physician Office Skilled Nursing Facility Vendor Address 1: Address 2: City: State: Zip: Contact Information First Name: Last Name: Job Title: Phone Number: Email:   Electronic Information Authorization 278 Claim Status 276/277 Claims 837 Dental Claims 837 HCFA Claims 837 UB-92 DDE Claims 837 HCFA DDE Claims 837 UB-92 EFT Eligibility 270/271 Enrollment 834 Premium 820 Proprietary Formats Remittance 835   General Information What clearinghouses do you currently interface? ACS Emdeon ENS Gateway EDI MedAvant Misys Office Ally PerSe Post & Track SSI Group THIN Other clearinghouses not listed above? What is your Practice Management Software? Please list top 5 payors you interface with? Payor Volume Would you like to be contacted for an AdminisTEP demo? Yes Please No Thank You