Get Jurisdiction 11 A/b Mac Edi Enrollment Provider Authorization Form

Filling out the Jurisdiction 11 A/B MAC EDI Enrollment Provider Authorization Form online is essential for authorizing a clearinghouse or billing service to submit and receive electronic claims data on your behalf. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form online successfully.

1. Click the ‘Get Form’ button to access the Jurisdiction 11 A/B MAC EDI Enrollment Provider Authorization Form and open it for editing.
2. Indicate the line of business and state for which you will be transmitting. Be sure to select all applicable options related to your request.
3. Specify the action requested regarding the services you are authorizing the submitter to access. Check all relevant options based on your needs.
4. Enter the provider name as it appears on the CMS 855 Medicare Enrollment Application. Ensure it matches exactly to avoid processing issues.
5. Input the Tax Identification Number for the provider accurately.
6. Provide the provider's email address, which will receive important EDI notifications.
7. List the Provider Transaction Access Number (PTAN) for the Medicare claims that the submitter will access. Note that a separate form is required for each PTAN.
8. Indicate the National Provider Identifier (NPI) for the provider.
9. Fill out the name and title of the contact person for Palmetto GBA to reach out to if there are questions.
10. Provide the mailing or physical address of the provider. Only one address is required.
11. Enter the city, state, and ZIP code of the provider.
12. Input the area code and phone number for the contact person listed.
13. Enter the name of the submitter you are authorizing.
14. Sign the form in the space provided, ensuring you are the authorized contact for the provider.
15. Enter the date of signature.
16. Once all fields are completed, save your changes, and prepare to download, print, or share the completed form.

Complete your documents online to ensure a smooth submission process.