Get Us Department Of Labor 770447710377104 Pre-enrollment

Filling out the US Department of Labor 770447710377104 Pre-Enrollment form is an essential step for ensuring proper electronic data interchange within the Office of Workers' Compensation Programs. This guide provides a clear and structured approach to help users complete the form accurately and efficiently.

Follow the steps to fill out the form online effectively.

1. Click the ‘Get Form’ button to access the pre-enrollment form and open it in your preferred editor.
2. Begin by indicating your classification in Section A1. Select from the options: Software Vendor, Switch Vendor, Provider, Clearinghouse, or Billing Agent.
3. In A1, provide your submitter/vendor/provider name, address, city, state, zip code, telephone number, fax number, provider number, employer identification number (EIN), group provider number, and your email address.
4. Indicate your provider specialty in Section A2. If your contact information differs from Section A1, enter the contact name and title, business address, city, state, zip, phone number, fax number, and email address.
5. If identified as a Software Vendor in Section A1, complete Section A3 with the software name, software version, protocol, and whether you have clients submitting to ACS.
6. In Section A4, select the electronic submission method: vendor software, clearinghouse, billing agent, proprietary, or X12N. Specify the transaction type: professional, dental, institutional, HCFA, or UB.
7. In Section A5, indicate if you are interested in retrieving your transactions electronically, and specify who will retrieve your reports and which reports you would like to access.
8. After filling out all sections completely, review the form for accuracy. Save your changes, download, print, or share the form as needed. Finally, submit the completed form via fax or mail.

Start completing your documents online now for efficient processing.