Ohio ACE - QESP Claim & Administrator Updates

Ohio ACE - QESP Claim & Administrator Updates
Information about the Organization
You must be an Authorized Party by your Organization to complete this application form. Authorized Party means you are authorized to transact or authorize transactions for all business relating to any deposit account which transfers of funds may be made through Online Banking for the corporation, partnership, limited liability company or other business organization or a city, town, village, school district or other governmental body which you are representing on this application form.
Click here to find your QESP number
QESP Number*
www.aceohio.org/marketplace
Information about the Current Administrator
Name of the current Administrator must match what we have on file*

First NameLast Name
Email of the current Administrator*
This is the email that is currently receiving alerts when claims are waiting to be processed.
What would you like to do? *Select all that apply*

Add a new Claim Reviewer (a person that can process claims)Change the Primary Reviewer (the person who receives new claim notification and payment notification emails)Change the Primary Administrator (this person is responsible for all claim reviewers and the organizations participation within the ACE program)Add an additional Administrator (this person is also responsible for all claim reviewers and the organizations participation within the ACE program)
Information about the new Administrator

This person is responsible for all claim reviewers and the organizations participation within the ACE program.
Name of the new Claim Administrator

First NameLast Name
Phone Number of the new Claim Administrator
This will not be public, it will only be used to contact you about your registration.
Email of the new Claim Administrator
This is the email that will be the primary point of contact for this organization
Your Role or Position at Organization
Your Government-issued Photo ID (must not have blurred out sections)

Please upload a copy or photo of a Government-issued Photo ID. Only the front side is needed, but your name must be legible and photo clearly identifiable.
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Employment Verification Letter (Required if your name is not on the business license)

This letter must be on a letterhead from your organization and contain all of the following: (1) organization name and (2) complete organization address, (3) current job title of the employee, (4) employment dates, along with the (5) explicit approval to act on behalf of the organization, and the (6) name, (7) signature and (8) contact details of the person who prepared the letter.
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Information about the additional Administrator

This person is responsible for all claim reviewers and the organizations participation within the ACE program but will not be the primary point of contact for this organization.
Name of the additional Administrator

First NameLast Name
Phone Number of the additional Administrator
This will not be public, it will only be used to contact you about your registration.
Email of the additional Administrator
Role or Position at Organization
Your Government-issued Photo ID (must not have blurred out sections)

Please upload a copy or photo of a Government-issued Photo ID. Only the front side is needed, but your name must be legible and photo clearly identifiable.
Cancelof
Employment Verification Letter (Required if your name is not on the business license)

This letter must be on a letterhead from your organization and contain all of the following: (1) organization name and (2) complete organization address, (3) current job title of the employee, (4) employment dates, along with the (5) explicit approval to act on behalf of the organization, and the (6) name, (7) signature and (8) contact details of the person who prepared the letter.
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Information about the Primary Claim Reviewer

This person will be the primary point of contact for all claims. They will receive emails when claims are pending reviews and when/if payments have been made to the service provider.
Name of the Primary Claim Reviewer

First NameLast Name
Email of the Primary Claim Reviewer
This is the email that you want to receive alerts when claims are waiting to be processed.
Information about the Additional Claim Reviewer

This person will have the ability to process claims but will not receive any email notifications.
Name of the Additional Claim Reviewer

First NameLast Name
Email of the Additional Claim Reviewer
Would you like to add more claim reviewers?

YesNo
Information about the Additional Claim Reviewer

This person will have the ability to process claims but will not receive any email notifications.
Name of the Additional Claim Reviewer

First NameLast Name
Email of the Additional Claim Reviewer
Would you like to add more claim reviewers?

YesNo
Information about the Additional Claim Reviewer

This person will have the ability to process claims but will not receive any email notifications.
Name of the Additional Claim Reviewer

First NameLast Name
Email of the Additional Claim Reviewer
Sign and Submit
Please verify that you are human*
I hereby attest that I am authorized to represent the Organization I am enrolling in the OHIO ACE program. I understand and agree to all the terms and conditions for participation in the OHIO ACE program and attest that all eligibility statements made herein are materially true and correct. If my organization is providing invoices for reimbursement, my ACH information must be linked with Merit to be reimbursed. I understand that failure to provide the committed educational services for verified purchases may result in removal from the program and will require the return of grant funds for that purchase. I further understand that fraud of any kind under this program constitutes interstate wire fraud and will be punished to the full extent of the law.

Additionally, any changes to my organization's services will be communicated to Merit within five business days. Merit reserves the right to edit a Qualified Service Providers Marketplace listing to provide clarification, eligibility information, requested changes, and errors.

By providing my phone number, I consent to receive text messages from Merit International, Inc. ("Merit") in relation to my participation in this program, program updates, and other pertinent messages about the Service. I acknowledge that Merit will be sharing my phone number with the ACE Ohio program to strictly be used in conjunction with the administration of this program. Text message opt-in is not a condition of participation in this program or using Merit's Service. I understand messaging and/or data charges may apply. Messaging frequency may vary. I understand that I can unsubscribe anytime by contacting help@gomerits.com or clicking the unsubscribe link (where available).
Signature*

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Ohio ACE - QESP Claim & Administrator Updates

Information about the Organization

Information about the Current Administrator

Information about the new Administrator

Information about the additional Administrator

Information about the Primary Claim Reviewer

Information about the Additional Claim Reviewer

Information about the Additional Claim Reviewer

Information about the Additional Claim Reviewer

Sign and Submit