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ELECTRONIC DATA 51105 INTERCHANGE (EDI) ENROLLMENT

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INTERCHANGE (EDI) ENROLLMENT. All fields marked with * are required and must be completed. Reference Materials are available on the last page of this document. A. Part A (Institutional) Part B (Professional)B * PROVIDER INFORMATION (Required) (Must match the name for the Group/Billing Provider on file with Medicare as reported on the CMS-855 ...

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