CMS Federal Program Contractor’sLogo HereElectronic Data Interchange Enrollment Agreement • September 16th, 2008
This Agreement notifies (fill in contractor name here) 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.
CMS Federal Program Contractor’sLogo HereElectronic Data Interchange Enrollment Agreement • September 16th, 2008
This Agreement notifies (fill in contractor name here) 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.
Electronic Data Interchange (EDI) Enrollment FormElectronic Data Interchange Enrollment Agreement • August 16th, 2012
This Agreement notifies (fill in contractor name here) 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 Medicare data covered under Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets legislation.
Provider Sign-up Form InformationElectronic Data Interchange Enrollment Agreement • August 23rd, 2007
On page 6, fill in the area marked “Providers For Whom Submitter Will Be Transmitting”. Additional providers can be listed on page 7.
Electronic Data Interchange Enrollment AgreementElectronic Data Interchange Enrollment Agreement • January 21st, 2019
This agreement is between “Provider,” a licensed provider or supplier of health services, and Administrative Services Only, Inc. (ASO), as to rights and obligations pertaining to automated submission and processing of ASO claims, claims status requests, and eligibility, as follows:
Direct Data Entry (DDE) Electronic Data Interchange (EDI) Enrollment FormElectronic Data Interchange Enrollment Agreement • December 13th, 2017
This Agreement notifies Wisconsin Physicians Service Insurance Corporation 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 the Centers for Medicare & 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.
