EDI Enrollment Forms

To enroll in EDI, download and complete the paperwork below. The completed documents should be mailed to:

Attn: EDI
ActivHealthCare
P. O. Box 1368
Lilburn, GA 30048

Adobe Acrobat Reader
	Download Adobe Acrobat Reader Adobe Acrobat or Adobe Acrobat Reader is required to open the .PDF files listed below.
Required Enrollment Documents:
DO NOT SEND THE THREE REQUIRED ENROLLMENT FORMS DIRECTLY TO OFFICE ALLY. Your claims will not be processed properly unless your enrollment paperwork is mailed directly to ActivHealthCare. This does not apply to the optional enrollment documents.
	AHC EDI Provider Agreement Addendum Additional document required with the Agreement.
	Office Ally EDI Business Agreement Agreement between the Provider and Office Ally to provide electronic claims processing.
	Office Ally Enrollment Form The enrollment form required for set-up for electronic claims processing.
Optional Enrollment Documents:
AHC provides Medicare enrollment forms on the website for your convenience. You may download the documents and mail them as specified on the individual applications. AHC is not involved with the processing of Medicare, Medicaid, BCBS, or other non-AHC claims. DO NOT MAIL THESE OPTIONAL FORMS TO ACTIVHEALTHCARE.
	Georgia Medicare Enrollment Instructions
	Georgia Medicare Part B Provider Application for EDI This form must be completed to electronically file Medicare claims through Office Ally. You do not need to complete this form if you will not be processing Medicare claims.
	Tennessee Forms (For Georgia providers with Tennessee patients only.)
	Tennessee Medicare Enrollment Instructions
	Tennessee Medicare Part B Provider Application for EDI This form must be completed to electronically file Medicare claims through Office Ally. You do not need to complete this form if you will not be processing Medicare claims.
	Tennessee Blue Cross Blue Shield Pre-Enrollment Form