# Remit AI Onboarding

## Organization Information

**Company name**

**Please Upload Your Logo**

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**How many practices do you have in total?**

**How many Tax IDs (TIN) do you have?**

Please complete this [template](https://docs.google.com/spreadsheets/d/1HI5-Ya-F_lv9L9d_NG7JKxluUMhn_nKm/edit#gid=1117033777) 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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Please upload your insurance collection report by payer over the last 12 months.

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**Has your practice previously enrolled into EFTs and/or ERA?**  
Yes  
No

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

**PMS**

**Clearinghouse**

### Bank information to ERA/EFT Enrollment

**Do you have more than one bank account?**  
Yes  
No

Please follow the instructions in the first tap of this [template](https://docs.google.com/spreadsheets/d/108Ymy3q2yX9sdEzWZ0YRgwOielgI7co1-TQXAE-v2Nw/edit#gid=230643160) and upload it below.

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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

**First name**

**Last name**

**Email**

**Phone number**

**Fax number**

### Software Agreement / Payment

**Zentist BAA & HIPAA**  
BAA & HIPAA Compliance 05/2022  
/6

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

**I Agree**

**Your Full Name**

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