B2B Health Contact Us

Contact Us - Health Division

Please provide all appropriate information. This data is used to allow access to our secure B2B site with access to the CORE ERA and EFT Enrollment forms.

Fields marked with * are required.

Provider Information

Provider Name *

(Includes individual medical provider, facility, clinic, etc.)

Tax ID (TIN) *

(Multiple TINs or NPIs require multiple Contact Us forms to enable multiple enrollment access.)

Entity Type Code

(Entity Type Code 1 : Individual, 2 : Organization)

NPI ID *

Provider Address

Street *

Street (line 2)

City *

State *

Zip *

Provider Contact Information :

Provider Contact Name *

Telephone Number *

(Provide direct phone number for use during B2B registration.)

Fax Number

Email Address *

Additional Information Required

Are you acting on behalf of provider *

Only complete this section, if you will be completing the ERA EFT Enrollment forms on behalf of the provider

Vendor Name

Contact Name

Telephone Number

Email Address

Fax Number

Email Address

Fax Number

ERA or ERA/EFT Enrollment, provide the Method of Retrieval

Method of Retrieval

UHIN #

Comments/Reason for contact (750 Characters)

By choosing to send a message to State Farm, you acknowledge that all information contained in your message, including questions, comments, suggestions, etc., shall not be deemed confidential, and State Farm shall have no obligation of any kind whatsoever with respect to such information, and shall be free to use, reproduce, disclose, and distribute the information to others without limitation.