Government of Ontario: Ministry of Health and Long-Term Care

EDT Registration
PO Box 68
Kingston ON K7L 5K1

Application for Interdisciplinary Health Provider (IHP)
GONet Electronic Data Transfer (EDT) Service

Instructions :

This application must be signed.
Solo/group providers and billing agents must complete the EDT Undertaking and Acknowledgement (form no. 4721–84) and attach it to this application.
Solo and group providers must complete Parts A to E.
Billing agents and vendors must complete Parts A, B and E.
Applications signed by a third party (e.g. Group Administrator, Director, President, Owner, Licensee etc) must indicate their name and title / position.
Return this application to the address at the top of the form. Allow 4 to 6 weeks for processing.
For information contact: MOHLTC Help Desk 1 800 262–6524 or 613 548–7981.

Connectivity Method : Direct Dial
ENA
SSHA
Other

Do you use a Network Provider? No
Yes (Identify)

Part A : Registration

Your billing type (check one only) : Solo
provider number
Group
group number
billing agent
vendor

Part B : Applicant Information

Last Name
First Name
Initial
Dr. Mr. Mrs. Ms.
Organization Name
Address
City
Province
Postal Code

Telephone No. ( ) ext.

Fax Number ( )

Security Code Word Maximum of 20 characters.

Note : You must provide a security code word. This security code word will be requested by the Ministry to verify your identity as a registered user.

Part C : Fee-for-Service Claims Submission

Your report(s) will be delivered to your own GONet EDT User ID unless you indicate otherwise. If you wish to have your report(s) delivered to an alternate GONet EDT User ID, please provide that User ID in the space(s) below :

1. Claims Batch Edit Report
GONet EDT User ID
Name/Organization

2. Claims Error Report
GONet EDT User ID
Name/Organization

3. Claims Remittance Advice
GONet EDT User ID
Name/Organization

Remittance Advice Sequence : Health/OHIP/Registration Number OR Accounting Number

Request for changes must be received by the Ministry of Health and Long-Term Care thirty (30) days prior to a change becoming effective to ensure the service provider's data is forwarded to the correct User ID.

Will your claims be prepared for you by an external billing agent? No
Yes (specify name of billing agent)

Part D : Overnight Batch Eligibility Checking (OBEC) (OBEC is not available to billing agents at this time)

Do you wish to apply for the Overnight Batch Eligibility Checking Service (only available to providers who register for fee-for-service claims submission). OBEC reports will be returned to the GONet EDT User ID of the individual submitting the file.

No Yes

Part E : Applicant's Signature

Signature

Date
Name (print full name)
Position or Title
Preferred EDT Start Date (yyyy/mm/dd)

Part F : Ministry of Health and Long-Term Care Use Only

Claims test required No Yes

GONet EDT User ID assigned
User ID
Temp. password
District code
OCCS station no.
Operator number
Effective EDT date (yyyy/mm/dd)
EDT end date (yyyy/mm/dd)
Processed by
Date