NGS -- Jurisdiction B DME MAC List Serve Registration Form

Jurisdiction B DME MAC List Serve Registration Form

Required fields are marked with * below.



Email Address*
Fax Number
First Name*
Last Name *
Title
Company*
Address*
State*	If state not on menu, select "Other" and fill in box.
ZIP/Postal Code*
Phone *


Please identify which of the following descriptors best describes your role in the Medicare program. *	Please check all that apply: -Beneficiary -Billing Service/Software Vendor -Clearinghouse (receives/transmits claims to appropriate contractor) -Contractor/Government Employee (CMS, Medicare, Medicaid, etc) -Established / Prospective Healthcare Supplier -Software Vendor (Sells software products for the purpose of EDI) -Third Party Payor / Insurer -Other *If you choose this option, please explain in the comments below.
Do you currently use the National Government Services' Express Plus software program to transmit claims electronically?*
In addition to general Medicare updates, which specific area(s) would you like to receive updates on?*	Please check all that apply: -Durable Medical Equipment (DME) -Dialysis Supplies and Equipment -Drugs -Electronic Data Interchange (EDI) -I.V./Parenteral and Enteral Nutrition (PEN) -Orthotics and Prosthetics (O&P) -Refractive Lenses -Rehab / Mobility -Respiratory -All List Serves


Comments:


Supplier Number (NSC#):