Free ForwardHealth Trading Partner 835 Designation, F-13393 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13393 (08/08)

STATE OF WISCONSIN

FORWARDHEALTH

TRADING PARTNER 835 DESIGNATION
Instructions: The Trading Partner 835 Designation form is to be completed by providers using third-party Electronic Data Interchange (EDI) trading partners. By completing this form, the provider certifies that the trading partner identified in Section III of this form is authorized to receive electronic X12 835 Health Care Claim Payment/Advice (835) transactions on the provider's behalf. Providers may submit this form by fax at (608) 221-0885 or by mail to ForwardHealth, EDI Department, 6406 Bridge Road, Madison, WI 53784-0009. Type or print clearly. Refer to the Trading Partner 835 Designation Completion Instructions, F-13393A, for detailed information on completing this form. SECTION I -- PROVIDER ADDRESS INFORMATION Name -- Provider Address Line 1 -- Provider

Address Line 2 -- Provider

City, State, ZIP+4 Code -- Provider

SECTION II -- PROVIDER INFORMATION NAME -- PROVIDER PROVIDER NUMBER

SECTION III --TRADING PARTNER INFORMATION NAME -- TRADING PARTNER TRADING PARTNER IDENTIFICATION NUMBER

SECTION IV -- AUTHORIZED REPRESENTATIVE By signing below, the provider's representative certifies that the trading partner identified in Section III is authorized to receive the 835 transactions on the provider's behalf. Name -- Authorized Representative Telephone Number -- Authorized Representative

SIGNATURE -- Authorized Representative

Date Signed -- Authorized Representative