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Forms
Instructions for Completing EDI Applications
Please read and follow instructions carefully. Applications that do not comply with these guidelines will be rejected and returned.
- Access the application by clicking on the appropriate link below. You must have Adobe 8 or later installed on your system to complete these applications.
- Complete the application by typing your information online, directly into the application.
- Once completed, print the application, obtain an authorized signature, and fax it to Cahaba EDI Services. Applications must be faxed to the number provided in the top right corner of the first page of the application.
- Pages must be faxed in the order printed. Use only the cover page provided with the application and make sure it is the first page faxed.
- Send only one application per fax.
- If an e-mail address is provided on the application, it will be used to send notifications when the application status changes.
- If you are completing the EDI Services Part A System Access Request to request FISS access for new employees you must provide a four digit PIN for each person. This PIN must be different for each person requested.
- If you are resubmitting an application that has been returned, you must complete and fax a new application.
- Billing services and clearing houses must complete the “EDI Services Part A Billing Service Application.” If using in-house software that requires testing, a provider's “EDI Services Part A Application” is also required. The provider's application must be in front of the billing service application and sent in the same fax.
- Vendors must complete the EDI Services Part A Vendor Application.
- New vendors will need to fax at least one provider's EDI application along with the “EDI Services Part A Vendor Application.” The provider's application must be in front of the vendor application and sent in the same fax.
- For new connectivity vendors the Network Services Agreement with an authorized signature must also be submitted.
- The name, address, and tax ID provided must match the address and tax ID we have associated with the PTAN and NPI in our system. If submitting multiple PTANs, the name and address on the application must match the first PTAN/NPI combination.
- If you must attach a separate sheet to list all of the PTANs or users, this should be placed after the last page of the application.
- If you have any questions contact EDI Services at (866) 582-3253, or via e-mail at PartAEDIServices@cahabagba.com
Click the link to the appropriate application below to begin entering the data. You must have Adobe 8 or later installed on your system to complete these applications.
- Part A Application
- Part A Billing Service Application
- Part A Vendor Application
- Part A Network Service Vendor
- Part A System Access Application
Page last updated: February 19, 2010
