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Get Ohio Medicare Part B Change Form - Lindsay Technical Consultants

Hattanooga, TN 37402-0061 Blank forms may be copied. Call Lindsay Technical Consultants, Inc. (888) 941-8967, if you have any questions. Palmetto GBA EDI OH and WV Part B Provider Change Form This form is to be completed by a Provider when the following changes occur: Discontinue use of a billing agent or clearinghouse Use of a new billing agent or clearinghouse Required fields are noted with an asterisk (*). * Provider Name: * Contact Name: * Mailing Address: * City: * Phone #: * E-mail Addr.

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