Remit AI Onboarding

Leave us a note, and we’ll call you! We’re excited to help you end complicated dental insurance billing forever!

Organization Information

Company name

Please Upload Your Logo

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How many practices do you have in total?

How many Tax IDs (TIN) do you have?

Please complete this template with the practice information, then upload it below. Please review and complete all 3 tabs.

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Online Insurance Website Portal Logins

Please upload your consolidated insurance login information file.

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Please upload your insurance collection report by payer over the last 12 months.

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Has your practice previously enrolled into EFTs and/or ERA?

Yes

No

Please list your previous enrollments for EFTs & ERAs below:

Please add are there any payers you would like us NOT to enroll into EFT?
For example, Zelis or Echo

PMS and Clearinghouse

PMS

Clearinghouse

Bank information to ERA/EFT Enrollment

Do you have more than one bank account?

Yes

No

Please follow the instructions in the first tap of this template and upload it below.

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Max file size 10MB.

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Name of bank

Legal business name

Name on account

Bank account number

Bank routing number

Please upload a copy of W9

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Please upload a bank letter confirming banking information

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Administrator information for insurance portal enrollment

First name

Last name

Email

Phone number

Fax number

Software Agreement / Payment

Zentist BAA & HIPAA

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Your Full Name

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