New Submitters

• EDI Registration Package for New Submitters
• EDI Enrollment Form

Existing Submitters

• EDI Registration Package for Existing Submitters

Electronic Remittance Advice (ERA)

• Electronic Remittance Advice Form

Electronic Funds Transfer (EFT)

• CMS-588 Electronic Funds Transfer Form

For EFT enrollment, National Government Services must receive:

• A valid Medicare Identification number and NPI
• One EFT request form for each Medicare Identification number
• A voided blank check or bank affidavit (a pre printed deposit slip will not be accepted)

NOTE: This form cannot be faxed.

Mail forms to:

For Indiana
National Government Services
Provider Enrollment
P.O. Box 7158
Indianapolis, IN 46207-7165

For Kentucky
National Government Services
Provider Enrollment
P.O. Box 7149
Indianapolis, IN 46207-7149

PPTN Existing Users

• EDI Provider Recertification

Professional Provider Telecommunications Network (PPTN) New and Existing Users

• Professional Provider Telecommunications Network (PPTN) Form

Express Plus

• Express Plus