Iso Claimsearch - Medicare Secondary Payer Compliance Reporting Notification Form

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Medicare Secondary Payer
Compliance Reporting Notification Form
Please provide complete information for questions regarding your company’s Medicare
Secondary Payer, Section 111 mandatory reporting following the instructions below.
□
Our company plans to use ISO ClaimSearch as our reporting agent for
the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section
(Check if
Section 111 Mandatory Reporting.
applicable)
________________________________________________________
Signature
________________________________________________________
Date
Contact Information
CMS Program
Contact Name:
Title:
Company:
Member Type
□
□
□
(check one):
Insurer
TPA
Self Insured
Address:
Address Line 2:
City:
State:
Zip:
Phone:
Fax:
E-Mail:
Attn: Bryan Berkowitz
Return the
Compliance Specialist
completed form to:
ISO ClaimSearch
545 Washington Boulevard, 22-15
Jersey City, NJ 07310-1686
201-748-1073
Fax:
Email:

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