Complete this Registration Form when one or more of the following applies:

1. I have a new provider joining my practice.
2. I just got an organizational NPI and group PTAN for: Medicare/MCRR/DMERC/MCD.
3. I have a new PTAN for Medicare, BC, Medicare RR, etc. and want to send electronic claims.
4. I have linked the new provider to my existing electronic submitter number.
5. I have applied for and received my NEW electronic submitter #'s (be sure to submit the documentation from the payer with the registration form).
6. I have a new provider that is already linked to our group Tax ID and NPI and we are ready to send claims to Medicare/BC/MCRR/DMERC/MCD/ Commercial claims.
7. I need to change my office address.