Examples of ERA in a sentence
DISABLED INDIVIDUAL • VIETNAM ERA VETERAN • GENDER any person who: - has a physical or mental impairment that substantially limits one or more major life activity(ies) - has a record of such an impairment; or - is regarded as having such an impairment.
Missing, illegible, or incomplete information will delay the set-up of the ERA or cause the enrollment form to be returned.
I understand that providing false or misleading information on this enrollment application will result in rejection from the ERA program and that I will be responsible for any fees, legal or otherwise, incurred by PrimeWest Health on my behalf.
Authorized Signature Printed name of person submitting enrollment* Printed title of person submitting enrollment* Submission date* Requested ERA effective date Instructions for Completing the ERA Authorization Agreement for Enrollment/Change/Cancellation Complete the Electronic Remittance Advice (ERA) Authorization Agreement form.
If one is not selected, PrimeWest Health will assume your ERA will be retrieved from the provider web portal.