Attachment Z

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File Transfer Setup Request Form – Attachment Z
This form is to be started by BeneTrac, then forwarded to Leah Pagliassotti at CONEXIS in order to set up submitting electronic files for the purpose of COBRA, HIPAA, Direct Bill, and FSA.

Client Information

|Type of services to be sent: COBRA HIPAA Direct Bill (retirees) FSA | |Name of the client: |RoundPoint Financial Group | |Tax ID: |26-1193089 | |Divisions YES or NO – 25 Capital Partners, RoundPoint Management, Inc., RoundPoint Mortgage Company, RoundPoint Mortgage Servicing Corp. | | CONEXIS System: CXO CXD CXA | |Frequency of file submission: Weekly | |File Naming Convention: CXDROUNDPOINTCOBRA | | BeneTrac EDI Coordinator: | |Name: |Eugene Abuan | | | |EAbuan@BeneTrac.com | |File Transfer contact: | | Name: |David Glaze |Phone: |(   )     -     |Email:...
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