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.

CMS strictly prohibits any trading partner from outsourcing system functions overseas, 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 by an overseas party 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 per the National Supplier Clearinghouse. If you have questions about the authorized signer, please contact the NSC at 1-866-238-9652 to determine who is authorized to sign the forms.