RemitAI Onboarding Form

Remit AI Onboarding

Organization Information

Company name

Please Upload Your Logo

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Max file size 10MB.

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How many practices do you have in total?

How many Tax IDs (TIN) do you have?

Please complete this template with the practice information, then upload it below. Please review and complete all 3 tabs.

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Online Insurance Website Portal Logins

Please upload your consolidated insurance login information file.

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Max file size 10MB.

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Please upload your insurance collection report by payer over the last 12 months.

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Max file size 10MB.

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Has your practice previously enrolled into EFTs and/or ERA?

Please list your previous enrollments for EFTs & ERAs below:

Please add are there any payers you would like us NOT to enroll into EFT?

For example, Zelis or Echo

PMS and Clearinghouse

Bank information to ERA/EFT Enrollment

Do you have more than one bank account?

Please follow the instructions in the first tap of this template and upload it below.

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Max file size 10MB.

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Name of bank

Legal business name

Name on account

Bank account number

Bank routing number

Please upload a copy of W9

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Max file size 10MB.

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Please upload a bank letter confirming banking information

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Max file size 10MB.

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Administrator information for insurance portal enrollment

Software Agreement / Payment

Please Click the box to agree to the BAA and HIPAA agreement

I Agree

Your Full Name

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