Wisconsin Physicians Service (Wps) Authorization Form For Electronic Remittance Advice Processing (Era) Page 2

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Provider Identification Numbers:
Multiple providers may be listed on this form if they are at the same location. To retrieve ERA for
additional providers at different locations, please complete a separate authorization form for each
additional provider number.
Provider/Group
Provider/Group Name
PTAN Number
Provider/Group NPI Number
* (Authorized signature of provider is one who is authorized to sign other legal documents on
behalf of the provider; (signatures from the billing service or clearinghouse are not accepted).
I,
of
would like to
(Provider Signature)
(Provider Name)
receive ERAs effective,
. (
All providers MUST include an effective date for this request)
(Date)
By checking this box, you are authorizing a Third Party Company/Clearinghouse to
X
Retrieve ERA files on your behalf.
Please supply the complete name and address of theThird Party Company/Clearinghouse.
Name:
: __42496 Lindsay Drive_______
_
_ Address
Lindsay Technical Consultants, Inc.
City: _North Mankato_____ State: __MN____ Zip: _56003_____ Fax #:____507-947-3077_________
Gary Lindsay
Contact: __
__________________ Contact Phone #:____507-947-3070________
(Printed Name)
(Please include extension #)
Contact Email Address: __info@lindtech.com_________________________________________
Translation Software: If you are a direct submitter, you will need translation and printing software in
order to view and print the Electronic Remittance Advice. MREP software, for part B providers, and
PCPrint software for part A providers, is available to download from our website at the following address
under MREP and PCPrint Software:
Please mail or fax this completed agreement to:
Medicare Part A & B J5 MAC(IA, KS, MO, NE)
Medicare Part A & B J8 MAC(IN & MI)
Medicare Part A Legacy
Medicare Part B
WPS Medicare EDI
(Multiple States)
(IL, MN, WI)
1717 West Broadway
WPS Medicare EDI
WPS Medicare EDI
Madison, WI. 53713
PO Box 1602
912 N Pentecost Drive
Fax:
(608) 223-3824
Omaha, NE 68101
Marion, IL 62959
Phone: (866) 503-9670
Fax: (402) 995-0606
Fax: (618) 998-5170
Phone: (866) 734-6656
Phone: (877) 567-7261
Version 1.0
Modified 7/06/2012
Page 2 of 2

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