Fillable Cms Secure Net Access Portal (C-Snap) Internet Remittance printable pdf download

Cms Secure Net Access Portal (C-Snap) Internet Remittance

Download a blank fillable Cms Secure Net Access Portal (C-Snap) Internet Remittance in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Cms Secure Net Access Portal (C-Snap) Internet Remittance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

CMS Secure Net Access Portal (C-SNAP) Internet Remittance

This remittance option is available to those receiving paper remittances only.

This form is intended to discontinue receipt of the Standard Paper Remittance (SPR) by mail.

By choosing this option, you are electing to print the SPR from C-SNAP and discontinue

receiving it by mail. The implementation process cannot begin until this form is completed. If the

form is received and is not legible or not completed correctly, it will be returned. Please

submit this form to the EDI Department, for the applicable line of business, as listed below.

***Please allow up to seven business days from our receipt of this form to process your

request. ***

Check all lines of business that apply:

Part A J5

Part B J5

Part A J8

Part B J8

J5 National Part A

Group/Provider National Provider Identifier (NPI) _____________________________________

Group/Provider Provider Transaction Access Number (PTAN) ___________________________

Effective Date ________________ (All providers must include an effective date for this

request)

Provider Name ________________________________________________________________

Provider Address ______________________________________________________________

City/State/ZIP ________________________________________________________________

Signature ____________________________________________________________________

Printed Name _________________________________________________________________

(Authorized signature of provider is one who is authorized to sign this or other legal

documents on behalf of the provider).

Title____________________________________ Date________________________________

C-SNAP User Login ID: _________________________

User Name ______________________________ Phone # _____________________________

User Email ___________________________________________________________________

Please mail or fax this completed form to:

Part A:

Part B:

WPS Medicare EDI

3333 Farnam St

912 N Pentecost Drive

Omaha, NE 68101

Marion, IL 62959

Fax (402) 995-0606

Fax (618) 998-5122

J5 Phone (866) 518-3285

J8 Phone (866) 234-7331

05/21/2015

Cms Secure Net Access Portal (C-Snap) Internet Remittance

Related Articles

Related forms

Related Categories