Trading Partner Agreement and Connectivity Form

Trading Partner Agreement and Connectivity Form
All entities wishing to submit claims through 837 HIPAA files must be connected to the Alliance Claim System (ACS). Access to ACS can be initiated or updated via this form.

If the entity is using a clearinghouse, billing service or third-party biller, please fill out the applicable box. For detailed instructions, see page 3 of the linked form.
Select the choice that best matches you:*

This is a new trading partner agreement (TPA)This is an update to an existing trading partner agreement (TPA)
Submitter's email*
example@example.com
I. Provider information*

Regardless of who submits the form, the relevant provider information is required
1. Provider name*
Legal provider name on Alliance Health contract
2. Business legal name (if different)
Another name that may apply
3. NPI*
National Provider ID
NPI 1
NPI 2
NPI 3
NPI 4
NPI 5
NPI 6
NPI 7
NPI 8
NPI 9
NPI 10
Provider contact information

Authorized representative for the trading partner
4. Provider contact name*
5. Title*
6. Contact email*
example@example.com
7. Phone*
(888) 888-8888
II. Clearinghouse information

This applies only if you are a clearinghouse or will be using a clearinghouse.
8. Clearinghouse name
9. Contact name
Authorized representative for the trading partner
10. Title
11. Contact email
example@example.com
12. Phone
13. Address (street, city, state, postal code)
Address used in mailings
14. Tax ID
Tax ID of clearinghouse
TIN 1
TIN 2
TIN 3
TIN 4
TIN 5
TIN 6
TIN 7
TIN 8
TIN 9
III. Billing service/Third-party biller

This applies only if you are using a billing service or third-party biller.
15. Company name
16. Contact name
Authorized representative for the trading partner
17. Title
18. Contact email
example@example.com
19. Phone
20. Address (street, city, state, postal code)
Address used in mailings
21. Tax ID
Tax ID of billing service or third-party biller
TIN 2.1
TIN 2.2
TIN 2.3
TIN 2.4
TIN 2.5
TIN 2.6
TIN 2.7
TIN 2.8
TIN 2.9
Please indicate whether the 835 should be sent to a Provider, Clearinghouse/Biller, or both.

Send 835 to ProviderSend 835 to Clearinghouse/Biller
Trading partner signature (type your full name)*
Date signed

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Trading Partner Agreement and Connectivity Form

I. Provider information*

Provider contact information

II. Clearinghouse information

III. Billing service/Third-party biller