EDI ENROLLMENT FORMEdi Enrollment Agreement • February 15th, 2013
This Agreement notifies Wisconsin Physician Services of the provider’s consent to participate in Electronic Data Interchange (EDI). EDI may include claims and claims attachments, remittances, eligibility/benefits, claim status, and any other electronic information for Centers for Medicare and Medicaid Services (CMS) federal program data (including but not limited to Title XVIII of the Social Security Act (Medicare), and/or Section 1011 of the Medicare Modernization Act) covered under Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets or Section 1011 of the Medicare Modernization Act (MMA) legislation.
Part A/Part B/HHH EDI Enrollment (Agreement) Form and InstructionsEdi Enrollment Agreement • June 9th, 2020
The EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed only by the providers to ensure each provider is knowledgeable of the enrollment request and the associated requirements.
Back to FormEdi Enrollment Agreement • August 30th, 2023
The EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed only by the providers to ensure each provider is knowledgeable of the enrollment request and the associated requirements.
Part A/Part B/HHH EDI Enrollment (Agreement) Form and InstructionsEdi Enrollment Agreement • January 24th, 2018
The EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed only by the providers to ensure each provider is knowledgeable of the enrollment request and the associated requirements.
EDI ENROLLMENT AGREEMENT INSTRUCTIONSEdi Enrollment Agreement • June 9th, 2020
The Railroad EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed by the provider, administrator or legal representative to ensure each provider is knowledgeable of the enrollment request and the associated requirements.
Part A/Part B/HHH EDI Enrollment (Agreement) Form InstructionsEdi Enrollment Agreement • November 14th, 2022
The EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed only by the providers to ensure each provider is knowledgeable of the enrollment request and the associated requirements.
EDI ENROLLMENT AGREEMENT INSTRUCTIONSEdi Enrollment Agreement • September 12th, 2016
The Railroad EDI Enrollment Form (commonly referred to as the EDI Agreement) should be submitted when enrolling for electronic billing. It should be reviewed and signed by the provider, administrator or legal representative to ensure each provider is knowledgeable of the enrollment request and the associated requirements.
