Get Dde Enrollment Form

Completing the Dde Enrollment Form online is essential for Medicare Part A providers seeking access to claims processing and beneficiary eligibility information. This guide will provide clear, step-by-step instructions to help you accurately fill out the form and submit it successfully.

Follow the steps to complete the Dde Enrollment Form online.

1. Click ‘Get Form’ button to obtain the Dde Enrollment Form and open it in your preferred document editor.
2. Indicate the line of business and state under which you will be transmitting information. Ensure you select the appropriate options.
3. Enter the Submitter ID if available, otherwise leave it blank for new applicants. This ID will be assigned by Palmetto GBA.
4. Provide the date when the application is completed to keep a timeline of your submission.
5. Enter the entity name, which could be a provider, corporate office, vendor, billing service, or clearinghouse requesting DDE access.
6. Select the type of entity from the given options to correctly classify your application.
7. Fill out the EDI contact person's name. This individual will be the point of contact for any inquiries about the application.
8. Provide the phone number and fax number for the contact person to allow for direct communication regarding the enrollment.
9. Input the mailing address, including city, state, and ZIP code of the entity for record-keeping purposes.
10. Enter the email address of the contact person. This will be the primary method of correspondence.
11. List each provider's name along with their PTAN (Provider Transaction Access Number) and NPI (National Provider Identifier) for whom Online Inquiry Services access is being requested.
12. Select the action requested by checking the corresponding box, such as requesting a new ID, deleting an existing ID, or reinstating a previous ID.
13. Complete the personal details for each individual needing a DDE ID, making sure to include their full names, middle initials, and any existing ID/PIN.
14. After reviewing all the entered information for accuracy, save your changes, download the document, print it or share it as needed.

Complete the Dde Enrollment Form online and enhance your access to Medicare information today.