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Register for Secure File Transfer

If you would like secure access to Fallon Health’s Secure File Transfer, please fill out the form below. Upon receipt and review by Fallon, your assigned username and password will be forwarded to each authorized individual. If you do not hear back from us within 15 business days, please call 1-866-275-3247, option 6, fax us at 1-508-368-9996 to confirm receipt or email us at edi.coordinator@fallonhealth.org.

PERSONAL/GROUP/FACILITY INFORMATION

Trading partner name:

Identification number:

(NPI for Providers and Customer Number for Employer Groups)

Address line 1:

Address line 2:

City:

State:

ZIP:

ELECTRONIC SUBMISSION INFORMATION

Please select the method of electronic submission you would like to use:

If you indicated third party/bill agent, enter the billing agent/clearinghouse name:

If you indicated third party/bill agent, enter the actual vendor name:

Technical contact name:

Phone number:

Please enter the phone number in the following format: 123-123-1234.

Fax number:

Please enter the fax number in the following format: 123-123-1234.

EDI transaction type: (Indicate transation type as 837, 834, 276,270, 278)

What is the average size of EDI files to be submitted? 1-3MB 4-6MB 10MB or more

How often will EDI files be submitted? Daily Weekly Monthly

How many files, on average, will be submitted?

USER ACCESS

FALLON's Secure File Gateway (SFG) allows trading partners to submit electronic claims and download electronic reports using multiple secure managed file transfer protocols. The SFG provides the ability for HTTPS, SFTP, and FTP/SSL connections. Below is a short description of each protocol, please check the protocol you will use. If you are not sure which Protocol you are using, please contact your vendor.

Which protocol will you use?

The FALLON secure website allows individuals to login with their secure credentials and submit electronic files. - This option is for a MANUAL LOGIN, Scripting should not be used with this option. The FALLON SFTP server allows trading partners to automate their processes to submit files electronically. We need your IP address for this option.

If you choose SFTP, please enter your IP address(es):

User 1 first name: Please list all individuals who will be accessing Fallon systems. It is the responsibility of the client to notify Fallon when an individual listed below leaves the employment of the client or has a legal name change. Failure to do so may result in the agreement being terminated.

User 1 last name:

User 1 phone number:

Please enter the phone number in the following format: 123-123-1234.

User 1 email address:

User 1 999/TA1 Acknowledgment:

User 2 first name:

User 2 last name:

User 2 phone number:

Please enter the phone number in the following format: 123-123-1234.

User 2 email address:

User 2 999/TA1 Acknowledgment

User 3 first name:

User 3 last name:

User 3 phone number:

Please enter the phone number in the following format: 123-123-1234.

User 3 email address:

User 3 999/TA1 Acknowledgment

User 4 first name:

User 4 last name:

User 4 phone number:

Please enter the phone number in the following format: 123-123-1234.

User 4 email address:

User 4 999/TA1 Acknowledgment

AGREEMENT TERMS

I will protect all usernames and passwords given to me during this registration process from unauthorized use and disclosure. I understand that I am responsible for all actions performed while accessing Fallon Health’s Tools. I will notify Fallon Health immediately by calling 1-866-275- 3247, option 6, if I believe a password has been compromised. I will notify Fallon Health to disable access when an employee’s responsibilities no longer require using Tools, or when an employee terminates. I understand that as the provider of health care services, employers or trading partner or delegate, I am responsible for compliance with all federal and state requirements regarding the confidentiality of health care information, and that I have responsibility for the actions and use of that information for those users I have designated access. The undersigned agrees to indemnify and hold harmless Fallon Health for any breach of this confidentiality agreement, and shall be liable to Fallon Health for any such breach of this agreement and damages resulting from such breach, including, but not limited to, interference and contractual relations, interference with advantageous relations, loss of any contract and any other losses and/or damages together with Fallon Health’s expenses in connection with the breach, including, but not limited to, costs, accountant fees, consultant fees and reasonable attorney’s fees. I authorize Fallon Health to receive and process EDI transactions in accordance with applicable regulations. I assure that all information submitted is accurate and any claims submitted in falsification are prosecutable under state and/or federal laws. All information provided on the Fallon Health website is accurate to the best of our knowledge. Fallon Health shall not be liable for any claims, loss or damage resulting from its use.

Legal name of vendor organization:

Individual authorized to sign for organization/title:

Click here to attest that you have read and agree to the terms presented above:

Please enter today's date:

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Register for Secure File Transfer

PERSONAL/GROUP/FACILITY INFORMATION

ELECTRONIC SUBMISSION INFORMATION

USER ACCESS

AGREEMENT TERMS

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