CMS HETS ENROLLMENT / Provider Attestation

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the EDI Registration Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the EDI Registration Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the Connectivity Agreement Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the Clearinghouse Agreement Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

To what e-mail address should WPS respond to your request?

E-mail Address

Submiting Data...

This may take several minutes

[ Please Do Not Close This Window]

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the EDI Registration Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

Signature

Submiting Data...

This may take several minutes

[ Please Do Not Close This Window]

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the EDI Registration Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

Signature

Submiting Data...

This may take several minutes

[ Please Do Not Close This Window]

By typing my name below, I certify that I have reviewed the listed agreement(s), that the information contained in the EDI Registration Summary of each agreement is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).

Signature

Submiting Data...

This may take several minutes

[ Please Do Not Close This Window]

Please read the displayed agreement carefully as it is legally binding. If you agree to all of the terms in the agreement, type your name in the Signature field below and click the Submit Agreement(s) button.

By typing my name below, I certify that I have reviewed the displayed agreement(s), that the information contained in the Registration Summary is complete and accurate to the best of my knowledge, that I am authorized to request the identified transaction(s) and that I authorize said transaction(s).