Palmetto GBA
Palmetto GBA

Required items feature an asterisk (*).

Contact your Medicare Contractor for all technical issues regarding eServices, including problems with registration and login. Please do not duplicate your Medicare Contractor inquiry by also submitting this form. Use this form to provide eServices feedback. We welcome your comments. Please complete the form below and click the 'Submit Feedback' button.

In order to ensure your privacy, please do not transmit any of the following information to Palmetto GBA. Revealing this information online could expose you or others as a target for Medicare fraud and abuse.
  1. Personal information, including Social Security numbers, which you would like to keep private.
  2. Beneficiary information, including Medicare Beneficiary Identifiers (MBIs), Health Insurance Claim (HIC) Numbers, coinsurance and deductible information, dates of Medicare entitlement, copies of or information from Medicare claim forms, Medicare reports of eligibility, and Medicare Summary Notices (MSNs).
  3. Information covered under the Freedom of Information Act (1967) and/or the Privacy Act of 1974.
  4. Claim specific data.

First Name: *
Last Name: *
PTAN/Provider Number:*
City: *
State: *
Zip Code: *
Phone: *
Extension: *
Email: *
Subject: *
Please retype the following two digit number*:

© 2024, Palmetto GBA, LLC