CEDI Supplier Authorization Form

U.S. Department of Health and Human Services

Select Transactions Authorized for this Submitter

ASC X12 837 Claim V4010A1

ASC X12 276/277 Claim Status & Response V4010A1

ASC X12 835 Remittance V4010A1

NCPDP Claims

Submitter and/or Receiver Information

Entity Name

Operating as a

Submitter ID

Street

City/State/Zip

Contact Name

Phone Number

Ext

E-mail

Verify E-mail

DME Supplier Information

Supplier Name

Street

City/State/Zip

Contact Name

Phone Number

Ext

E-mail

Verify E-mail

List your NPI and your NSC/PTAN Number(s) Below (Required): PTAN(s)

NPI

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.

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.

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