Home : Site Map : Contact Us : On-line Enrollment 

On-line Enrollment

Getting started with EZ-DME Billing Services

If you are interested in our Billing Services, please complete the information below. Upon completion, EZ-DME will email the necessary forms to you to sign and return.

* Denotes a required Field

Company Name
*Legal Business Name
*DBA Name
Physical Address
*Address
Address
*City
*State	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	*Zip
Mailing Address	If different from Physical Address
Address
Address
City
State	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip
Contact Info
*Contact Name
*Authorized or Delegated Official
Title
*Phone		*Fax
*Email Address
Legal Info
NCPDP / NABP #
*NPI#
*Federal Tax (EIN)#
Dea#
Medicare DME Provider#
Medicare Part B Provider#
Medicaid DME Provider#
Buying Group or PSAO
Software Vendor / Version
Are you interested in billing DME supplies to commercial carriers?
Are you interested in billing Flu Shots?
Are you interested in billing Medicaid DME supplies?
Do you have additional locations to contract at this time?
Do you have additional locations already using our billing services?
Would you like a phone call to discuss services?
CEDI Authorization
Do you authorize HCC to receive your 835/EOB electronically?
Do you authorize HCC to complete all Medicare CEDI forms on your behalf with the information listed above?
Notes:
When you are finished click "Submit" to send this form to EZ-DME.

 

Top of page