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k karea Go Practice Kareo EDI Enrollment Thank you for selecting Kareo as your practice management software! The Payer EDI Enrollment process for electronic services allows you to send electronic claims to, and receive electronic remittance reports from, over 3,000 commercial and government payers through the Kareo application. TRANSFER OF AUTHORIZATION FORM Signed applications must be submitted to the [Dl department of each insurance to approve your new electronic connection. The insurance payer must recognize the vendors that are electronically transmitting your claims and receiving your remit files. For Kareo to better handle your enrollments, we ask that you authorize Kareo to sign payer EDI agreements on your behalf. This agreement must be signed by an authorized officer of the practice. This is usually the main provider or business executive (e.g. owner, president, CEO, etc.). This person should also be the contact on file with the insurances as they will check for a match when processing forms. Instructions: 1. Print this form. Fill and sign where needed. 2. Scan the document as a .pdf file in black and white. Avoid color scans or picture images. 3. Upload the file into the Kareo PM Documents section. a. Log into Kareo and open practice. b. Under the Documents menu, click to Add Document. c. Select "Other" for Document Label. d. Enter the Document Name as "TAF." e. Attach file and save. This will help Kareo to easily locate the document when processing your request. The signed authorization must be uploaded into the PM as soon as possible to avoid delays in processing your payer enrollment requests. For any questions, please reach out to Kareo for assistance. lore° Go Practice Transfer of Authorization for EDI Enrollment , declare that I am an officer of (Your name, as Representative of the Company) Chairman, Board of Supervisors Maricova County by and through Department of Public Health and that I have the authority to sign (Company Name) this authorization on the company's behalf. , hereby authorize Kareo, Inc. and its (Your name, as Representative of the Company) Chairman, Board of Supervisors enrollment representatives to act on our behalf in all activities relating to electronka data interface/ED! enrollment (including signing of all documents relating to these matters). • All acts of enrollment carried out by Kareo, Inc. and its enrollment representatives on our behalf have the same effect as acts of our own. • I shall provide Kareo with all necessary information (for example, N PI numbers, tax ID numbers, etc.) for the limited purpose of Ka reo completing the forms. • I acknowledge that Kareo will rely on the accuracy of the provided information. Printed Name Chairman, Board of Supervisors Title Signature Date FOR AND ON BEHALF OF MARICOPA COUNTY ATTEST: kareo Clerk of the Board Go Practice Date Signature Samples APPROVED AS TO FORM: Attorney for Maricopa County Please sign in the center of the boxes below. Date Signature #1 Chairman, Board of Supervisors Signature #2 Chairman, Board of Supervisors Signature #3 Chairman, Board of Supervisors