The following J1 EDI Enrollment Agreement should be submitted when enrolling for electronic billing. It should be reviewed and signed only by the provider to ensure each provider is knowledgeable of the enrollment request and the associated requirements.

Providers that have contracted with a third party (clearinghouse/network service vendor or a billing agent) are required to have an agreement signed by that third party in which the third party has agreed to meet the same Medicare security and privacy requirements that apply to the provider in regard to the viewing or use of Medicare Beneficiary data. These agreements are not to be submitted to Medicare, but are to be retained by the providers.

Providers are obligated to notify Medicare by letter of:

• Any changes in their billing agent or clearinghouse.
• The effective date of which the provider will discontinue using a specific billing agent or clearinghouse.
• If the provider wants to begin to use additional types of EDI transactions.
• Other changes that might impact their use of EDI.

Providers are not required to notify Medicare if their existing clearinghouse begins to use alternate software, the clearinghouse is responsible for notification in this instance.

Note: The binding information in an EDI Enrollment Agreement does not expire if the person who signed the form for a provider is no longer employed by the provider.

The PDF copy of this form is interactive. From your Adobe Reader, you can type directly into the form fields on the form. Use the Tab key to navigate through the form. Once complete, please print, sign (if required) and mail the form to the appropriate address noted.

To download the EDI Enrollment Form, click on the link below.  The file is a PDF file and is viewable using Adobe Reader. Click here to download Acrobat Reader at no cost.