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Electronic Commerce Forms

Electronic Data Interchange (EDI) Enrollment

Electronic Funds Transfer

Electronic Remittance Request *

Submitter Action Request Form

www.ivans.com/empire

Medicare Part A Provider Logon Request Form

Provider Authorization Form

PC-ACE/PC Print Software Order

* Part A Electronic Remittance Request Note: Please request the 835 V4010A1 test file electronically. The Submitter will receive an automatic email once the form is delivered to EMS. EMS will send notification by email at the end of the week to the Submitter regarding their effective date for test files. If the Submitter wants more tests after the 5 calendar days, then another completed 835 Request Form will be completed.

When the Submitter is ready to move into production they must notify EMS in writing. At that time only the 835 V010A1 will be created. The paper remittances will be discontinued after 30 calendar days from the date of when the new 835 Receiver is placed into production.

Page Last Modified: 12/17/2007

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