First Name *
Last Name *
Email *
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Company *
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Title *
I am a... * Developer looking to learn about API Vendor looking to learn more about being a reseller to Availity solutions
Do you have an Availity account? * YesNo
What is your Availity customer ID? *
What is your average transaction estimate per month? (Including claims, authorizations, eligibility & benefits, etc.) *
How will your system transmit information to Availity? (Please select all that apply) * SFTP 837 835 HTTPS wxml wrapper 270 271 276 277 278 REST API - JSON
Which electronic transactions are being requested? (Please select all that apply) * 837 - Claims 835 - ERA 2701 Realtime SoapWS REST API 276 277 Claim status Realtime SoapWS REST API 278 Auth Referral Realtime SoapWS REST API
When would you like to start testing/go-live with a production account? * Within the next 3 weeks Between 1-3 months Between 4-7 months More than 8 months
Which of these software types best describe your company? * EMR Practice Management System Billing Software Ambulatory Software Long-Term Care Software Behavioral Health Software Patient Portal Dental Software Other
Are you able to generate ANSI 837 files? * YesNo
How many providers do you work with currently? *
How does your organization operate and what are you looking for specifically? Please include any other details that you think would be helpful for our conversation: *
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