University of Utah Health Plans - EDI Form

(835 and EFT Enrollment)

Provider Information

Provider Identifier Information

Do you have multiple Billing NPI’s (Type 2) under this TIN?

Provider Contact Information

Provider Remittance Advice Clearinghouse Information

Financial Institution Information for EFT Enrollment Only (Note: To receive the ERA it must be linked to an EFT)

Submission Information

Submitter Information

Has the provider ever submitted a claim?


This EFT request form authorizes University of Utah Health Plans to deposit funds for claims payment directly into a vendor's bank account. This request form also allows for reversal of payments that were made in error. This authority is to remain in full force and effect until University of Utah Health Plans has received written notification from the vendor of its termination in such time and manner as to afford University of Utah Health Plans a reasonable opportunity to act on it.

EDI participation is not an indication of contracting status. To verify contracting status, please contact customer service at (801) 587-6480.

EDI Department, University of Utah Health Plans
Email: uuhpedi@hsc.utah.edu