Trading Partner Enrollment Instructions   Skip portlet
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Trading Partner Enrollment Instructions
Please complete this form if you will be submitting HIPAA compliant transactions on behalf of a provider. If you are a provider please log into the provider web portal and click the Trading Partner Enrollment link located under Quick Links.
 
  1. For all date fields, use the date format (mm/dd/yyyy) unless otherwise indicated.
  2. Complete all areas of the application, unless otherwise indicated.
  3. After completing each page of your application, click "Continue" button to continue application process and follow the steps to validate your application.
  4. Some forms must be signed and sent in to complete your online trading partner enrollment. Original signatures are required. Copied or stamped signatures are unacceptable.


You may save a partial application at any point after completing the Identifying Information page. You may use the Application Tracking Number to recall the application that you have partially completed.

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