Medicare Offline Billing Software Request

Person Submitting Request:

Requester's Company Name:

Requester's Company is:

Select One Provider Vendor Clearinghouse Billing Agent Home Office

Medicare Provider Name:

Medicare Provider Number(s):

Mail Software to Name:

Address:

City:

  State:   Zip:

Phone Number:

    Fax Number:

Email Address:

Return check along with request form and two original,
signed MOBS License Agreements to: 
Medicare EDI Coordinator
Mailstop: AX1MC3
TriSpan Health Services, Inc.
P.O. Box 23046
Jackson, MS 39225-3046

Authorized Signature:	Date:
Print Name: