About Broker Resources Provider Resources 330-363-6360 Contact Us Account Login FIND A PLAN MEMBER RESOURCES EMPLOYER RESOURCES FIND A PROVIDER Notices HIPAA Electronic HIPAA Transactions Prior to downloading your form, please note the following: Forms listed here are in Portable Document Format (PDF). You will need Acrobat Reader plug-in to open PDF files. If you do not have Acrobat Reader, please visit the Adobe website to download the plug-in. 835 Online Enrollment Form (Require Account Login) 270/271 5010 Companion Guide 276/277 5010 Companion Guide 820 5010 Companion Guide - Not available at this time. Email edisupport@aultcare.com with questions 834 5010 Companion Guide 835 5010 Companion Guide 835 EFT Enrollment Instructions 835 ERA Enrollment Instructions 837 5010 Companion Guide 837 Electronic Claim Submission Enrollment Trading Partner Agreement Vendor Registration Guide AultCare Phone: 800-344-8858 330-363-6360 TTY: 711 24-Hour Nurse Line: 866-422-9603 330-363-7620 Customer Service Hours: Monday - Friday 7:30 am - 5:00 pm EST Mailing Address: 2600 Sixth St S.W. Canton, OH 44710 IRS Notice 2020-76 AultCare Insurance Company will not be automatically mailing 2020 Form 1095-Bs to members. However, upon request, any applicable members can have their 2020 Form 1095-B. To receive your 2020 IRS Form 1095-B, submit the request via our CONTACT US on our website or send the request to: AultCare Insurance Company 2600 Sixth ST SW Canton, OH 44710 You can also call us at 330-363-6360 or 800-344-8858 with any questions. Your request will be furnished within 30 days of receipt. Additional Resources HIPAA Privacy Policy Terms & Conditions Language Access Quality Careers COVID-19 Information Social Non-discrimination Notice AultCare/Aultra complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sexual orientation, gender identity, or sex. AultCare/Aultra does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AultCare/Aultra provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). AultCare/Aultra provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages.If you need these services, or if you believe that AultCare/Aultra has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can contact or file a grievance with the: AultCare/Aultra Civil Rights Coordinator, 2600 6th St. S.W. Canton, OH 44710, 330-363-7456, CivilRightsCoordinator@aultcare.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights staff is available to help you.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html © 2021 AultCare. All rights reserved.