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EDI Third-Party Provider 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
13102 NGS Part B-Connecticut
13202 NGS Part B-NGS
13292 NGS Part B-Queens County
Submitter and/or Receiver Information
Submitter/Receiver Name:
Operating as a:
Submitter ID:
Street:
City/State/Zip:
Contact Name:
Contact Phone Number:
Contact Email Address:
Provider Information
Provider Name:
(SAME if NOT different from above)
Provider Number(s):
National Provider ID (NPI):
Street:
City/State/Zip:
Contact Name:
Contact Phone Number:
Contact Email Address:
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