Centers For Medicare And Medicaid Services Edi Registration Form; And Edi Enrollment Form

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Centers for Medicare and Medicaid Services EDI Registration Form

1) General Information. Do not write in shaded areas of this form. Refer to instructions for Form completion. You must have a

Centers for Medicare and Medicaid (CMS) provider number (refer to CMS Form 855 to apply for a Medicare provider number)

prior to completing this Registration Form. This Form requires a signature.

Legal Business Name of CMS Provider

Billing Name of Provider /

Street Address

City, State, Zip

or Supplier Submitting this Form

Supplier

Contact Name

Phone Number

E-Mail Address

Fax Number

Name of Performing or Attending

National Provider

Billing Provider Number

Submitter Number

Physician

Identifier (NPI) Number

Name of Security Officer/Approver for

Assigned UserID

E-Mail Address

Telephone Number

Organization

(Optional)

2) Contractor Information

Contractor Name

Contractor

Effective Date

Number

EDI transaction or

Reason

Version

Name of

Name of Software

Data Transfer

Telecomm.

Service

for

Designated EDI

Vendor/ Product

Method

Request

Submitter/Receiver

URL:

A/C/D

URL:

837 Claim

NCPDP Claim

835 Remittance Advice

270/271 Eligibility

276/277 Claims Status

Other(specify)

3) Signed Authorization

This form must be completed and signed by all providers/suppliers to apply for initial use of EDI or to report subsequent changes in

the information furnished in a previously filed EDI Registration Form. This form is to be completed regardless of whether the

provider/supplier conducts EDI directly with CMS, and/or one of the CMS contractors or indirectly via a designated EDI

Submitter/Receiver. For additional information on completing this form, please visit the contractor’s website.

I certify that I am legally empowered to sign this Form on behalf of the Legal Business Name identified in Sections 1 of this Form. I acknowledge that it in

signing this, I bind this company or unincorporated organization to notify the CMS contractor in advance and in writing if changes have occurred to

information reported in this Form or if it is necessary to revoke any designations made in this Form. I certify that the information that I have supplied in

this Form is accurate.

As a CMS provider or supplier, I understand that in signing this Form, I am responsible for payment of any fees for EDI services charged by any designated

EDI Submitter/Receiver with whom I have elected to conduct business. I also understand that any acknowledgement, error reports, or query responses

related to submitted transactions will be returned to any designated EDI Submitter/Receiver with whom I have authorized on this form, and that CMS

contractors are not permitted to send duplicate copies of outbound transactions to my organization as well as to the designated EDI Submitter/Receiver.

Signature

Printed Name

Date

Title

Return the completed EDI Registration Form (either fax or hardcopy) to: (CMS contractor enters the fax number and address

information here)

* INCOMPLETE APPLICATIONS WILL BE RETURNED.*

CMS 0938-10164

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 0938-0983. The time required to complete this information collection is estimated to average

(hours) (minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the

information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500

Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850