Medicare Part A Provider Logon Request Form

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Medicare Part A Provider Logon Request Form

Section I: ACTION (required)

ADD No Yes

MODIFY No Yes

DELETE No Yes

Section II: REQUESTOR

PRIMARY CONTACT (required):	PHONE (required):
PROVIDER NAME (required):
ADDRESS (required):
CITY/STATE/ZIP (required):	TAXEIN (required):
AUTHORIZED PERSON'S E-MAIL ADDRESS (required):
AUTHORIZED SIGNATURE NAME (required):
TITLE (required):

Section III: INSTITUTIONAL PROVIDER

PRIMARY LEGACY NUMBER	PRIMARY NATIONAL PROVIDER ID (NPI)	AFFILIATED LEGACY NUMBER (S)	AFFILIATED NPI(S)
(required)	(required)

Section IV: FISS OPERATOR ACCESS

Please Indicate	I-(Inquiry)	N-(No access)
Beneficiary/CWF	HCPC Codes	Revenue Codes
Diagnosis/Procedure	DRG Pricer	Check History
Reason Codes - Adjustments/ANSI/FISS	Online Reports	Zip Code File

Please Indicate	Y - (Entry/Update/Inquiry)	*N - (No Access)*
Claims	Adjustments	ADR'S

Section V: LOGON

To submit additional provider numbers check here