Welcome to the DentaQuest Online Electronic Remittance Advice (ERA) Enrollment Request page. Please be sure to complete all of the required fields (marked with a star) and click on Submit before leaving this screen. Partial entries will not be saved.

There are two steps to complete before an ERA can be sent to your organization via a 5010 X12 835 transaction

1) Complete the Enrollment to receive the ERA below.
2) Complete the Trading Partner Agreement which can be accessed via the link at the end of this enrollment page.

Please enter the following information:

Provider/Organization/Practice Identification
Provider Name: *
Doing Business As Name (DBA):
National Provider Identifier(NPI): *
Provider Federal Tax Identification Number (TIN): *
Organization/Practice Contact Person
Provider Contact Name: *
Telephone Number: *
Email Address: *
Organization/Practice Address
Address 1 (Street Address or PO Box):
Address2 (Suite Number, etc.):
City:
Zip Code:
Country:	Select United States of America Canada
State/Province:	Select

We use an Agent for Processing Payments   Yes No

Provider Agent: Please enter your agent if you have one that receives your payments.
Provider Agent Name: *
Provider Agent Contact Name: *
Telephone Number *
Email Address *

Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Identifier)

Please choose aggregation type base on the identification used by your receiving bank on your bank account. If you are identified on your bank account by TIN, please choose TIN. If by NPI, please choose NPI. If you are identified by TIN, please do *not* choose NPI. The aggregation type must match your banking institution’s identification on your bank account.

Provider Tax Identification (TIN): National Provider Identifier (NPI):

Please enter information if you receive EDI transactions through a clearinghouse rather than directly.   Clearinghouse Name: * Clearinghouse Contact Name: * Telephone Number : * Email Address : *

Method of Retrieval: *	Clearinghouse from DQ web site FTP, Agent Direct
Reason for Submission *   New Enrollment: Change Enrollment: Cancel Enrollment:

A Trading Partner (TP) Agreement is required before DentaQuest can begin to send remittance advices electronically

I have a Trading Partner Agreement I do not have a Trading Partner Agreement

Trading Partner ID

Please type your name, date, and the requested effective date for this enrollment below:
Full Name	Submission Date	Requested Date