Pharmacy Provider Payment Set-up

PDMI sends physical payment and remittance to the mailing address or physical address of Pharmacy provided on the Credentialing Application or as updated otherwise via request or notification via DataQ information. Otherwise, Pharmacy may request an application for Electronic Funds Transfer (EFT) and electronic remittance (835) set up at its convenience. Please note that EFT enrollment requires an 835 enrollment. Applications are available via the links below.

835 Remittance Request Form 
EFT Payment Request Form 

Please email all completed 835 and EFT enrollment forms to our direct inbox at