Free ForwardHealth Managed Care Trading Partner Profile, F-13076 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13076 (07/08)

STATE OF WISCONSIN

FORWARDHEALTH

MANAGED CARE TRADING PARTNER PROFILE
Instructions: 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 Managed Care Trading Partner Profile Completion Instructions, F-13076A, for detailed information on completing this form. SECTION I -- MANAGED CARE TRADING PARTNER IDENTIFICATION NUMBER INFORMATION Type of Submission (check one) Initial Submission Update Submission SECTION II -- MANAGED CARE TRADING PARTNER INFORMATION Name -- Managed Care Trading Partner Address Line 1 -- Managed Care Trading Partner Trading Partner Identification Number Not Applicable

Address Line 2 -- Managed Care Trading Partner

City, State, ZIP+4 Code -- Managed Care Trading Partner

Name -- Electronic Data Interchange (EDI) Contact

Telephone Number -- EDI Contact

SECTION III -- MANAGED CARE TRADING PARTNER TRANSACTION SETS Indicate the transaction sets that the provider will receive. At least one selection is required. X12 820 Payroll Deducted and Other Group Premium Payment for Insurance Products X12 834 Benefit Enrollment and Maintenance SECTION IV -- AUTHORIZED REPRESENTATIVE The individual signing below must be a representative authorized by the managed care organization to conduct EDI-related business. Name -- Authorized Representative Telephone Number -- Authorized Representative Date Signed -- Authorized Representative

SIGNATURE -- Authorized Representative

For Office Use Only -- Trading Partner ID