Medical & Hospital ERA Enrollment Forms

Each provider must be set up in the Change Healthcare system to receive ERA files. A provider can submit an enrollment form themselves, or instruct their vendor to use our self-service enrollment portal to link you to the payer(s). If your vendor does not have access to the self-service portal, please see our category table below.

1. Step One: Specific payers require additional ERA enrollment paperwork to be completed for submission of claims. Please check the Change Healthcare Payer List for each payer's ERA Enrollment Requirements.
2. Step Two: If ERA paperwork is required by a payer, you must receive an approval from the payer prior to ERAs being received.

***NOTE: If hard-copy forms are submitted by a vendor that has on-line access to the Change Healthcare portal, the hard-copy forms will be rejected.

Commonly Used ERA Enrollment Forms

• ERA Merge Group Change of Vendor – PSF – Change of vendor
• ERA Merge Group Provider Setup Form – Create a merge group (splitting of ERA files)
• Optum Change of Vendor – Change of Clearinghouse to Change Healthcare for Optum Payers
• FTP TSO Request Form – Initial TSO Request for File Transfer Protocol (Vendor Only)
• SFTP TSO REQUEST FORM – Initial TSO Request for Secure File Transfer Protocol (Vendor Only)

ERA Payer Enrollment Forms