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National Government Services, Inc. CEDI Trading Partner Recertification Form

** ALL FIELDS MUST BE COMPLETED. AN INCOMPLETE FORM WILL BE RETURNED. ** Trading Partner ID: __________________________________ Trading Partner Name: _____________________________________________________________________ Primary Address: __________________________________________________________________________ City: ________________________________________ State: _________________ ZIP: _________________ Primary Contact Name: __________________________________ Phone #: ________________________ Fax #: _______________________________________ *Email: ______________________________________ Type of Trading Partner: ___ Supplier ___ Billing Service ___ Clearinghouse

List all supplier names and numbers connected to your Trading Partner ID listed above. If there is not enough room, please list additional numbers on company letterhead and attach to this form.

Supplier Name

Supplier NPI

Supplier NSC/PTAN

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Provide a list of individual (s) who will be responsible for all CEDI related activities under the Trading Partner ID listed above. Any contacts currently on file with CEDI who are not on the list below will be removed from CEDIs records. Any later changes to the individuals listed below must be communicated to CEDI by fax or email.

First Name

Last Name

Phone Number

CMS' information security policy strictly prohibits any trading partner from outsourcing system functions to any resource located outside of the United States or its territories. Prohibited outsourced functions include but are not limited to the transmission of electronic claims, receipt of remittance advice, or any system access to obtain beneficiary PHI and/or eligibility information. Violation of this policy will result in revocation of all methods of system access, including but not limited to EDI front end access or EDC RACF user access. The Medicare contractor shall notify all affected providers as well as reporting the system revocation to CMS. CMS' information security policy strictly prohibits the sharing or loaning of Medicare assigned IDs and passwords. Users should take appropriate measures to prevent unauthorized disclosure or modification of assigned IDs and passwords. Violation of this policy will result in revocation of all methods of system access, including but not limited to EDI frontend access or EDC RACF user access. The Medicare contractor shall notify all affected providers as well as reporting the system revocation to CMS.

___________________________________________________ Trading Partner ID Name (Print) ___________________________________________________ ________________________ Trading Partner ID Signature Date Please send your Recertification form to: Fax: (317) 5954999 Email: [email protected] Please retain a copy for your records. A confirmation email will be sent to the email address listed above. If you do not see an email, please check your bulk or spam folder.

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