Electronic Data Interchange (Edi) Enrollment Form Page 3

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by the provider. The responsibilities and obligations contained in this document will remain in effect as long as
Medicare/Section 1011 claims or any other EDI transactions are submitted to CMS or the CMS contractor. Either party
may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to terminate. In the
event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of
mailing, as established by the postmark or other appropriate evidence of transmittal.
C. Signature
I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing
provisions and acknowledge same by signing below.
Provider’s Name
Title
Address
City/State/Zip
Medicare provider number:
Submitter number (if applicable):
Signed By:
Printed Name:
Title
Date
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

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