Participation Agreement

Providers who wish to change their participation status in the Medicare program may do so during the open enrollment period. Participation Agreements must be postmarked on/before December 31, 2004.

To change your status from Non-participating to Participating, you must complete the Participation/Supplier Agreement (Form CMS-460) with the following information:

• Legal name
• Address
• Identification number(s) under which you will bill
• Telephone number
• Authorized Representative signature (please make legible)
• Date

If you have questions, please contact our Enrollment Representatives at 1-866-309-0486, Monday through Friday, 8:30 a.m. to 3:30 p.m.. Once the form is completed, fax it to 717-565-3430, or mail to one of the addresses listed below.

Mailing Addresses:

Empire Medicare Services Attn: Provider Enrollment 300 East Park Drive Harrisburg, PA 17111

Empire Medicare Services Attn: Provider Enrollment P.O. Box 69218 Harrisburg, PA 17106-9218

© 2004 Empire Medicare Services
_{http://www.empiremedicare.com}