Medicare Provider Name 
 
Contact Person   
Medicare Provider Number(s)
 
Phone Number   Fax Number
Email Address 
 

This is to authorize the third-party named below to perform the indicated services.
Third-party Name 

Operating as  

 

Select authorized service(s) on the left, then the purpose(s) for authorizing service(s) on the right.
Service   Purpose  
Direct Data Entry (DDE) Online Access                     Eligibility Verification
    Claims Entry
    Claims Status 
    Claims Correction/Adjustment 
Electronic Data Interchange (EDI) Electronic Claims Submission (EMC)
    Electronic Remittance Advice (ERA)
    Post Adjudication/Payments 
    Claims Status (276/277)
    Data Analysis/Generate Reports 
    Medicare Offline Billing Software (MOBS) 

Authorized Signature:
Title:
Print Name:
Date:

EDI-210A