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Get Request for Railroad Medicare PTAN for Electronic Submitters

For electronic claim submitters only. § § § § § § Please enter your information into this form prior to pressing the PRINT button. Any forms printed blank and then handwritten will cause processing delays. Provider(s) must have provided a service(s) to a Railroad Medicare beneficiary. Provider(s) must already be enrolled with your local Medicare Administrative Contractor (MAC). To enroll with EDI visit, www.PalmettoGBA.com/rr/edi This form may be completed for up to 5 providers, for more .

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