Wps Gha Portal Edi Enrollment Form (Page 4 of 4) in pdf

Wps Gha Portal Edi Enrollment Form Page 4

User Email __________________________________________

WPS GHA CLAIM ENTRY INFORMATION:

WPS GHA User Login ID: _________________________

User Name __________________________________________ Phone # _____________________

User Email __________________________________________

Please copy this page for any additional user login IDs that need WPS GHA claim entry functionality

for this provider.

Please mail or fax this completed agreement to:

Medicare Part B

J5 (IA, KS, NE, MO), J8 (IN, MI)

WPS Medicare EDI

PO Box 8128

Madison, WI 53708-8128

Fax:

(618) 998-5122

Phone:

J5B

866-518-3285 Option 1

J8B

866-234-7331 Option 1

Privacy Act Statement: Information you furnish on this form may be disclosed by WPS to another person or

government agency only with respect to the Medicare Program and to comply with Federal laws requiring or

permitting the disclosure of information or the exchange of information between the Department of Health and

Human Services and other agencies.

04/26/2016

Wps Gha Portal Edi Enrollment Form Page 4