New Submitters

• Submitter Action Request
• Provider Authorization Form
• EDI Enrollment Form

Existing Submitters

• Submitter Action Request
• Provider Authorization Form

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:
National Government Services
Provider Enrollment
P.O. BOX 4792
Syracuse, NY 13221-4792
  

PC-ACE Pro32 - Professional

• PC-ACE Pro32 Online Form
• PC-ACE order form