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EDI Report Request Form

NOTE: Reports are only available for 56 days.

Provider Information

Practice Name:
Contact Name:
Phone Number :
Email Address:
Provider/NPI Number :
Submitter Number :
Stratus ID:
State:

Please select the TYPE of Report. You may only select one report type.

Acknowledgement Report (997)
Electronic Receipt Listing
Electronic Remittance Notice

Please select the NUMBER of reports you are requesting.


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Centers for Medicare & Medicaid Services