E-Business Profile Smart Form

Submitter Type:
   
Type:
Submitter Name:
Physical Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Phone Number: (602-123-1234)
Fax Number: (602-123-1234)
   
   

Contact Information:
   
Office Contact:
Phone: (602-123-1234)
Fax: (602-123-1234)
Email: (name@whichever.com)
Alternate Contact:
Phone: (602-123-1234)
Fax: (602-123-1234)
Email: (name@whichever.com)

   

Computer Information
   
Name of Management System:
Version:
Electronic Claim Software
(if different from above):
Software Vendor:
Contact Name:
Phone:
Fax:
Email:
   
   

HIPAA Transaction Setup
   
Connectivity Method
FTPBatch Only
TumbleweedBatch Only
Socket to SocketReal-Time Only
MQ SeriesBatch Real-Time Both