Unless otherwise noted, all forms must be submitted with an original signature by mailing to:

Gainwell Technologies Provider Enrollment Unit

P. O. Box 80159

Baton Rouge, La. 70898-0159

Direct Deposit / EFT (Electronic Funds Transfer) Form

Electronic Remittance Advice (ERA) Form

EDI Contract and Power of Attorney Forms

File Update Form

Group Link/Unlink and Working Relationship Form

Hospital Specialized Unit Attestation Forms

Specialty Change Forms

Submitter/Provider Unlinkage Form

Disclosure of Ownership Forms