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EDI Report Request Tool

Updated: 02.07.19

NOTE: Electronic Remittance (835) Reports are only available for 45 days. Claim Response Reports are only available within 1 year of the current date.

Submitter Information

Submitter Name:
Contact First Name:
Contact Last Name:
Phone Number: - -
Email Address:
Provider NPI Number:
Submitter Number:

Please select the TYPE of Report. You may only select one report type.


Please select the NUMBER of reports you are requesting.


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