Form CMS-10164 Accesible EDI Registration Form

Medicare EDI Registration Form
1) General Information. Do not write in shaded areas of this form. Refer to instructions for Form completion. You must
have a Medicare provider number (refer to CMS Form 855 to apply for a Medicare provider number) prior to completing
this Registration Form. This Form requires a signature.

Legal Business Name of Medicare
Provider or Supplier Submitting this
Form

Street Address

City, State, Zip

Billing Name of
Provider / Supplier

Contact

Phone
No.

E-mail

Fax

Name of Performing or
Attending Physician

NPI

Billing Provider #

Submitter #

2) Contractor Information
Contractor Name
EDI transaction or
Service

Contractor Number
Reason for
Request
A/C/D

Version

Name of Designate Name of Software
EDI
Vendor/Product
Submitter/Receiver
URL:
URL:

Effective Date
Name of
Method
URL:

Data Transfer
Method
URL:

Telecomm.
Method
URL:

837 Claim
NCPDP Claim
835 Remittance Advice
270/271 Eligibility
276/277 Claims Status
Other(specify)
3) Signed Authorization
This form must be completed and signed by all Medicare providers/suppliers to apply for initial use of EDI or to report subsequent changes in the information
furnished in a previously filed Medicare EDI Registration Form. This form is to be completed regardless of whether the provider/supplier conducts EDI
directly with the Medicare contractor or indirectly via a Designated EDI Submitter/Receiver. For additional information on completing this form, please visit
your Medicare contractor’s website.

I certify that I am legally empowered to sign this Form on behalf of the Legal Business Name identified in Sections 1 of this Form. I acknowledge that in signing
this, I bind this company or unincorporated organization to notify the Medicare contractor in advance and in writing if changes have occurred to information
reported in this Form or if it is necessary to revoke any designations made in this Form. I certify that the information that I have supplied in this Form is accurate.
As a Medicare provider or supplier, I understand that in signing this Form, I am responsible for payment of any fees for EDI services charged by any Designated
EDI Submitter/Receiver with whom I have elected to conduct business. I also understand that any acknowledgement, error reports, or query responses related to
submitted transactions will be returned to any Designated EDI Submitter/Receiver with whom I have authorized on this form, and that Medicare contractors are not
permitted to send duplicate copies of outbound transactions to my organization as well as to the Designated EDI Submitter/Receiver.

Signature
Title

Printed
Name

Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938- 0983. This form expires on xx/xx/xxxx. The time required to complete this information
collection is estimated to average ( 20 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

Return the completed Medicare EDI Registration Form (either fax or hardcopy) to:
(Medicare contractor enters the fax number and address information here)
* INCOMPLETE APPLICATIONS WILL BE RETURNED.*
Instructions for Completion of the Medicare EDI Registration Form

CMS-10164

Many parts of the Medicare EDI Registration Form are self-explanatory. Following is supplemental information to assist
the provider/supplier in completing the form.
(1) General Information
Legal Business Name of Medicare Provider or Supplier Submitting this Form
tax purposes.

the name you use when reporting to the IRS for

Street Address, City, State, Zip Provide the street address, city, state, and zip code for the Legal Business Name.
Billing Name of Provider/Supplier Enter the provider/supplier billing name (can be the same as Legal Business Name). Enter
the name of a contact person, phone number, email and fax that corresponds to the billing name.
Name of Performing Physician or Attending Physician for claims filing with Medicare carriers, enter the performing physician.
For claims filing with Medicare intermediaries, enter the attending physician.
NPI Enter when available.
Submitter # new submitters may leave blank; if a group practice, report the group submitter #.
Billing Provider #. Enter your billing provider number. Group members must report Group number. If you have been issued
more than one Submitter Number or Billing Provider Number, enter those numbers on a separate piece of paper using the same
table format of Section 1.
(2) Contractor Information
Contractor Name Contractor enters its own name on form prior to making available to providers/suppliers.
Contractor Number Contractor enters its own number on form prior to making available to providers/suppliers.
Effective Date This is the date that you want to have your change take effect that is associated with your Reason for Request.
Reason for Request Enter either “A” (add), “C” (change), or “D” (delete).
Version
Enter either “H1” (HIPAA 5010A1), “H2” (the named HIPAA version to replace H1), or “H3” (the named
HIPAA version to replace H2).
Name of Designated EDI Submitter/Receiver
space provided.
Name of Software Vendor Or Product
provided.
Data Transfer Method

Click the URL, choose from the available options and enter it on the form in the

Click the URL, choose from the available options and enter it on the form in the space

Click the URL, choose from the available options, and enter it on the form in the space provided.

Telecommunications Method

Click the URL, choose from the available options, and enter it on the form in the space provided.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938- 0983. This form expires on xx/xx/xxxx. The time required to complete this information
collection is estimated to average ( 20 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850