Terms and Conditions

I certify I have been duly and legally authorized to sign this form.

I understand I am using electronic means to sign this document, and I consent to signing this document electronically.

I understand by typing my information below, I am certifying I am the person identified by this information and by providing this information and clicking the "Continue" button will constitute my electronic signature.

I understand CMS information security policy strictly prohibits the sharing or loaning of Medicare-assigned IDs and passwords and I should take appropriate measures to prevent their unauthorized disclosure or modification. I further understand violation of this policy will result in revocation of all methods of system access, including but not limited to, EDI front-end access or VDC RACF user access.

Do you allow organizations outside the United States or its territories (offshore organizations) to use your NPIs to access eligibility data?*

Authorized Signer Information

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Signers of this form must be authorized to sign on behalf of the provider, as reported to the Provider Enrollment, Chain, and Ownership System (PECOS). If you are unsure who your authorized official is, please contact PECOS. Visit PECOS.cms.hhs.gov for PECOS access.

PTAN/NPI Information

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* * Contractor Code 15101 - J15 Part A KY 15201 - J15 Part A OH 15102 - J15 Part B KY 15202 - J15 Part B OH 15004 - J15 HHH *