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, 2007.

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