Medical Billing Data EDI Trading Partner Profile {4015}

Oregon Medical Billing Data EDI Trading Partner Profile Workers' Compensation Division Trading partner type (check all that apply) Jurisdiction Service Bureau/DCO Employer Insurer Third-party administrator Self-insurer EDI service provider Other (specify): Master trading partner information Legal name (no abbreviations): Sender ID: The Federal Employer Identification Number (FEIN) of your business entity. This, along with the nineposition postal code (ZIP+4), will be used to identify a unique trading partner. The Sender ID FEIN and postal code should be the same as those that will be used by the partner as the Sender ID in the header record of all electronic data interchange (EDI) transmissions from the partner. Sender ID FEIN: IP address: Postal code: Physical address: City, state, ZIP+4: Mailing address: City, state, ZIP+4: Contact information Business Name: Title: Phone: Fax: Email: Technical Name: Title: Phone: Fax: Email: If you have questions about this form, contact the EDI coordinator, 503-947-7742, or email ed.c.lanssens@state.or.us. Send to: Workers' Compensation Division, Operations Section, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309 Or fax to 503-947-7514 Or email to dcbs.edimedical@state.or.us 440-4015 (10/13/DCBS/WCD/WEB) 4015 American LegalNet, Inc. www.FormsWorkFlow.com