Edi enrollment 2026

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4.9 out of 5

42 votes

The EDI Enrollment Form is an agreement between a provider and Wisconsin Physician Services, allowing the provider to participate in Electronic Data Interchange (EDI) for Medicare and Section 1011 transactions. It outlines the provider's responsibilities regarding data security, consent for claims submission, and compliance with HIPAA regulations. The document also details CMS's obligations to the provider, including timely payment and acknowledgment of claim receipt. The agreement remains effective as long as EDI transactions are submitted, with provisions for termination by either party.

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Click ‘Get Form’ to open the EDI Enrollment Form in the editor.
Begin by entering your Provider Name, Title, and Address in the designated fields. Ensure all information is accurate for proper identification.
In the 'Signature' section, provide your printed name, title, and date of signing. This confirms your authorization to submit the form.
Check all applicable lines of business and types of transactions that apply to you. This helps categorize your enrollment correctly.
Fill in your Group/Provider NPI Number and PTAN Number as required. If you are a batch biller, include your WPS Submitter Number.
If authorizing a third party or vendor, complete their details accurately in the provided fields to ensure they can process claims on your behalf.
Once all sections are filled out, review for accuracy before submitting via mail or fax as indicated at the bottom of the form.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (42 Votes)

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