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CEDI Supplier Authorization Form
U.S. Department of Health and Human Services
Select Transactions Authorized for this Submitter
Submitter and/or Receiver Information
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DME Supplier Information
    
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List your NPI and your NSC/PTAN Number(s) Below (Required):
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Enter the name and title of the person authorized to sign on behalf of the supplier below.
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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.
 
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.