CEDI Submitter Action Request Form

Section II - Software Vendor Information

Order the Free PC-ACE Software Program
Other

Vendor Name

Contact Name

Phone Number

Ext

Fax Number

Street

City/State/Zip

E-mail

Verify E-mail

Submitter Type

Are you a Clearinghouse or Third Party Service?

Are you a Vendor?

Section IV - Transactions

Select Transaction

Health Care Claim PRODUCTION (837 v5010A1) Health Care Claim Payment/Advice PRODUCTION (835 v5010A1) Health Care Claim Status Request & Response PRODUCTION (276/277 v5010) NCPDP D.0 PRODUCTION Health Care Claim TEST(837 v5010A1) Health Care Claim Payment/Advice TEST (835 v5010A1) Health Care Claim Status Request & Response TEST (276/277 v5010) NCPDP D.0 TEST

PTAN(s)

NPI Numbers

Enter the name and title of the person authorized to sign on behalf of the supplier below..

DME Supplier Signature

DME Supplier Title

IMPORTANT: Once you click on the "Submit" button, this form must be printed, signed, dated, and then faxed to CEDI using the fax number located on the form. Forms that are not printed, signed, dated, and faxed to CEDI will not be processed. Requests received 30 days past the Signature date will be returned.

REMINDER: CMS strictly prohibits the outsourcing of system functions outside the United States and its territories, unless explicitly authorized, in writing, by the CMS CIO. System functions include the transmission of electronic claims, receipt of electronic remittance advice or the access to any system for beneficiary and/or eligibility information. Any request for access received from outside the United States and its territories will be immediately denied by National Government Services pending authorization from CMS.

Signer of this form must be authorized to sign on behalf of the supplier, as reported to the National Supplier Clearinghouse. If you are unsure who your authorized official is, please contact the NSC at 866-238-9652.

ALL pages of ALL forms must be SIGNED, DATED, and FAXED to 315-442-4299 within 10 business days or the request will be rejected. Please be sure to fax multiple forms for the same request TOGETHER and include a cover letter. Faxes not received within 10 days of submitting the form(s) on line will be rejected and new forms will be required to be submitted.