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Jurisdiction 1 Part A
J1 EDI Enrollment Packet

Palmetto GBA has prepared this packet for J1 A/B MAC submitters of electronic claims. It contains forms and explanations for each of the services offered by our Electronic Data Interchange (EDI) department. For further information regarding any of this material, please call the Palmetto GBA Technology Support Center toll-free at (866) 749-4301.

Please allow a processing time of approximately four to six weeks. Remember - Palmetto GBA cannot process incomplete applications or agreements.

This packet contains the following forms in this order along with instructions on how to complete each form:

EDI FormsAccess this form by selecting this PDF link located on the bottom of this page 
 J1 EDI Enrollment Packet  EDI_Enroll_J1_Pack.pdf
 J1 Application Form  EDI_Enroll_J1_Appl.pdf
 J1 EDI Enrollment (Agreement) Form  EDI_Enroll_J1_Agree.pdf 
 J1 EDI Provider Authorization Form  EDI_Enroll_J1_Prov_Auth.pdf
 J1 Software Order Form  EDI_Enroll_J1_Software.pdf
 J1 Online Inquiry Services (DDE & PPTN) Enrollment Form  EDI_Enroll_J1_OnlineSvcs.pdf

Please Note: The J1 A/B MAC Electronic Funds Transfer (EFT) form is not included in the J1 EDI Enrollment packet. The J1 EFT Enrollment Packet is a posted separately and must be mailed to Provider Enrollment.

The PDF copy of these forms is interactive. From your Adobe Reader, you can type directly into the form fields on the form. Please click on the form fields to complete the form. Once complete, please print, sign (if required) and mail the form to the appropriate address noted.

To access the J1 EDI Enrollment Packet, select the link below.

 

last updated on 12/03/2009
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