Paperwork required for Medicare Submission of Enrollee Change or Application

1.    Articles of Incorporation
For private companies this establishes the ownership of the company. For counties and government organization this establishes the structure of the agency within the government frame.

2.    Tax Identification /  Verification Form
Medicare requires this to verify the status of the agency and to verify that privately held companies are registered with the proper tax agencies. If you cannot locate this form then you must request a new one to be mailed to you

3.    Copy of all ambulance charges
These are the charges that Colleton Software will place in our system in order to charge patients for the services your agency has provided

4.    Registrations on all ambulances

5.    State inspection sheet on all ambulances

6.    Titles on all ambulances (if available)
These registrations, inspections and titles are to verify that you have legal, state approved ambulance which are being used to transport patients

7.    Physical and Mailing Address, Phone numbers, Fax numbers for each location where ambulances are stationed
Each location where ambulance are stationed and serviced are dispatched from must be listed with Medicare.

8.    Copy of state license
This license proves to Medicare that you are licensed to conduct ambulance calls. This must be a valid non expired copy. Medicare will not accept a letter from the state or approve an application on an expired license

9.    A signed statement on letterhead, stating the following:
Tarheel Medical Billing, DBA Colleton Software is the ambulance billing for XXXX. Please submit all payments, remits and notifications to Tarheel Medical Billing P.O. Box 1308 Walterboro, SC 29488

10.    Banking Information where you want Electronic Transfers deposited
Colleton Software requires a bank name, account number, and a voided check. Medicare will not accept starter checks without the legal name on the actual check. If the company name does not match the name on the bank account EXACTLY then please contact our office for information on securing a letter from the bank to satisfy this requirement.

11.    Copy of their utility bill ( electric , or water)
This requirement is to verify the address and location.

12.    Letter stating specifications on billing procedures unique to your organization
This will include information on how the patient will be billed, how we handle balances after insurance payments, information on debt set off and collections. Please contact Mary Sparks if you have any