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Get MT DPHHS EDI Provider Enrollment Form

Complete all areas of the Submitter Enrollment Form, unless otherwise indicated. Section 1. Classification. Please indicate your classification. Software Vendor Billing Agent Clearinghouse Section 2. Submission Method. Please indicate how you plan to submit your electronic transactions. Asynchronous (Direct Submission to EDI) WINASAP5010 Section 3. Submitter Information. Business Name (If applicable) Provider Name (Last, First, MI, and Suffix) Business Street Address City, State, and .

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