Get Edi Enrollment Agreement Form - Office Ally

Filling out the EDI Enrollment Agreement Form is an essential step in the process of enrolling for electronic billing with Railroad Medicare. This guide offers a clear and supportive walkthrough of each section of the form, ensuring that you can complete it accurately and efficiently online.

Follow the steps to complete the EDI Enrollment Agreement Form online.

1. Press the ‘Get Form’ button to access the EDI Enrollment Agreement Form and open it in your preferred document editor.
2. Begin by entering your Railroad Medicare Provider Number and National Provider Identifier (NPI) in the designated fields. Avoid using your Tax ID Number as it is not required.
3. Review the agreement carefully, ensuring that all information is complete and accurate, including your address. It must match the one submitted during your provider enrollment.
4. The provider's full name should be printed clearly in the space provided, followed by the name and title of the authorized officer, alongside their original signature.
5. Make sure to date the form accurately, including the day, month, and year.
6. If you are submitting claims for multiple providers, ensure that each provider completes their own form.
7. Once you have finished filling out the form, save your changes. You can also choose to download, print, or share the completed EDI Enrollment Agreement Form as needed.

Complete your documents online today to ensure a smooth enrollment process.