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November 02, 2021

EDI Enrollment (Agreement) Form

The EDI Enrollment (Agreement) Form is needed for provider locations that have never billed electronically before. The agreement should be reviewed and signed by the provider’s office to ensure that the provider is knowledgeable of the enrollment request and the requirements.

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

Based on new system enhancements to process your paperwork faster and more efficiently, ALL NEW ENROLLMENT SETUPS will require an EDI Enrollment form in addition to the Online EDI Application and Provider Authorization Form. This is required by CMS for new PTAN/NPI setups. You may include the EDI Enrollment Form with the Provider Authorization Form when you fax to the EDI fax number on the Provider Authorization Form.

*If the PTAN is already setup electronically, you do not need to include an EDI Enrollment form.

For your convenience, the current link to the EDI Enrollment form is listed below. If it does not populate, copy and paste the link in your browser address window:


Please contact the EDI Helpdesk for assistance with rejected EDI Enrollment Agreement forms.

  • Part A: 866.590.6703, option 2
  • Part B: 866.276.9558, option 2
  • Home Health & Hospice: 877.299.4500, option 2


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