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