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O. Box 8128 1717 West Broadway Madison WI 53713 WPS Medicare EDI 608 223-3824 Fax Phone 800 782-2680 Email edi wpsic.com Phone 866 503-9670 Email Medicare part A edimedicarea wpsic.com For further updates visit our website at http //www. 1755 Telstar Drive Ste 400 Colorado Springs CO 80920 www. optum.com KSMCR Thank you for choosing Electronic Network Systems Clearinghouse a division of Optum to submit your Claims/ERAs. DEG3 Provider Contract Information Required. DEG4 Provider Agent...
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How to fill out the era enrollment form
How to fill out the era enrollment form
01
Step 1: Start by downloading the ERA enrollment form from the official website.
02
Step 2: Read the instructions carefully to understand the requirements and guidelines for filling out the form.
03
Step 3: Provide your personal information accurately, including your full name, address, contact details, and date of birth.
04
Step 4: If required, attach any supporting documents requested, such as proof of identification or proof of address.
05
Step 5: Fill out the enrollment form completely and legibly. Use black or blue ink and avoid any corrections or overwriting.
06
Step 6: Review the form to ensure all the information provided is correct and complete.
07
Step 7: Sign and date the form in the designated spaces.
08
Step 8: Make a copy of the completed form and keep it for your records.
09
Step 9: Submit the filled-out enrollment form through the specified submission method, whether it is online or by mail.
10
Step 10: Wait for confirmation or further instructions from the relevant authority regarding the status of your enrollment.
Who needs the era enrollment form?
01
Any individual who wishes to enroll in the ERA program needs to fill out the ERA enrollment form.
02
This could include students, professionals, researchers, or anyone seeking to benefit from the ERA program.
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The form helps gather the necessary information to process the enrollment request and ensure eligibility for the program.
04
Therefore, anyone who wants to participate in the ERA program must complete and submit the enrollment form.
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What is the era enrollment form?
The era enrollment form is a form that must be completed by entities who are enrolling in the ERA program.
Who is required to file the era enrollment form?
Entities who are interested in participating in the ERA program are required to file the era enrollment form.
How to fill out the era enrollment form?
The era enrollment form can be filled out online or submitted in hard copy with all required information.
What is the purpose of the era enrollment form?
The purpose of the era enrollment form is to collect information about entities enrolling in the ERA program.
What information must be reported on the era enrollment form?
The era enrollment form typically requires information such as entity name, contact information, and enrollment details for the ERA program.
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