Electronic Remittance Advice (ERA) Authorization Agreement Form Print

You may use the red Provider Login button to the left to access the Electronic 835 Authorization application and submit your request electronically.

Alternatively, you may click on the link below, print the form, fill it out, sign it with an original signature, and mail it to:

Gainwell Technologies EDI Department

P. O. Box 91025

Baton Rouge, La. 70821-9025

Electronic Remittance Advice (ERA) Authorization Agreement Form