Provider Enrollment Handout - Palmetto GBA

Signature Requirements□ Signature verification required for:□ Change of practice location□ Change of Corr/Special Payment address□ Change EFT□ Revalidation or Reactivation□ Establishment of sole owner or soleproprietor when provider currentlyreassigning all benefitsParticipation vs. Opt Out□ Participating: Accepts Medicareassignment□ Non – Participating: Option to acceptor not accept Medicare assignment□ Opt Out: Not enrolled/ does notparticipate in Medicare program□ Opt Out period runs for two years23