Register for Provider Tools and electronic data submission

If you would like secure access to Fallon Health’s Provider Tools, please have your office manager 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.

Provider information
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Please enter the phone number in the following format: 123-123-1234.
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Please enter the fax number in the following format: 123-123-1234.
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Please enter the phone number in the following format: 123-123-1234.
Are you a new or existing provider tools user?

Provider tools user authorization

Below, please list the employees to be granted access to Provider Tools through fallonhealth.org. To request access to Provider Tools for third-party agencies, complete the Billing Agency Authorization Form in addition to this form.

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Provider tool access for employee 1:




Please indicate the type of access you are requesting by checking the corresponding box.
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Provider tool access for employee 2:




Provider tool access for employee 3:




Access to PCP panel reports and referral monitoring report

If you would like multiple providers to have access to the authorization lookup tool, PCP panel reports and referral monitoring report, please fill out the information below. List the name and NPI number of provider in the office/group.

Select role:




Select role:




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Select role:




Select role:




Select role:




Agreement terms

The undersigned provider authorizes the above-named billing agency access to Fallon Health Provider Tools on fallonhealth.org to submit data to Fallon Health on the provider’s behalf. As such, the provider accepts full liability for all actions of the above named billing agency and is responsible for any violations of laws and regulations. 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 Provider 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 Fallon Health Provider Tools or when an employee terminates. I understand that as the provider of health care services 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 indemnity 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 shall not be liable for any claims, loss or damage resulting from its use.

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

To grant secure access to a third party billing agency for Fallon Health Provider Tools on fallonhealth.org, please fill out the form below. For any providers that are granting a third-party Billing Agency authorization to submit data to Fallon Health, a signature from both parties is required. We can obtain those signatures by requesting that the billing agency submit the provider enrollment packet and have the provider submit a note on company letterhead stating that they grant permission for the billing agency to submit data to Fallon on their behalf. Please submit all information to edi.coordinator@fallonhealth.org or fax to 1-508-368-9996. Upon receipt and review by Fallon Health, 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, or email us at edi.coordinator@fallonhealth.org to confirm receipt.

Please enter the phone number in the following format: 123-123-1234.
Please enter the fax number in the following format: 123-123-1234.
Allow access to the following tools:

Click here to attest that you have read and agree to the terms presented below:
The undersigned provider authorizes the above-named billing agency access to Fallon Health Provider Tools on fallonhealth.org to submit data to Fallon Health on the provider’s behalf. As such, the provider accepts full liability for all actions of the above named billing agency and is responsible for any violations of laws and regulations. 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 Provider 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 Fallon Health Provider Tools or when an employee terminates. I understand that as the provider of health care services 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 indemnity 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 shall not be liable for any claims, loss or damage resulting from its use.