National Government Services

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Subimitter Action Request Form

Section I:

Entity Name: (required)

Address: (required)

City: (required)	State:(required)	Zip:(required)

FED Tax EIN: (required)

Primary Contact: (required)	Telephone: (required) (xxx-xxx-xxxx)

Email Address: (required)	Fax: (required) (xxx-xxx-xxxx)

Section II:

Add SubmitterExisting Submitter (Add new provider or function to existing submitter)Change Submitter (Select if changing vendor)

Are you a Clearinghouse or other Third Party Service? YesNo

Section III:

Line of Business:
Medicare Part A (Institutional)Medicare Part B (Professional)

Section IV: (Please select Add or Change below)

Telecommunications Options: Add (Please See Note Below)Change (required)

Leased Line: Dial Up:

File Transfer Option (please select an item below)
FTP (link to TCP/IP Guide)
ZMODEM
OTHER
File Transfer Option
FTP (link to TCP/IP Guide and CSA)
ZMODEM (link to CSA )
OTHER

Note: To establish connectivity, please follow this site for approved telecommunications vendors: omnipro/solutions/connsol.htm

Section V:

Select Transaction:
Health Care Claim (837 V4010A1) (Companion Document - Part A ) (Companion Document - Part B )

Health Care Claim Payment/Advice (835 V4010A1) (835 Request form & Companion Document )

Health Care Claim Status Request & Response (276/277 V4010A1 - Medicare only) (Companion Document )

Health Claim Request for Additional Information (277 V4050 - Medicare only) (Companion Document )

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