Form Field Name | Instructions for Field Completion |
---|---|
* Submitter ID | The ID that was issued by Palmetto GBA upon completion of your EDI application form. This ID may be referred to as a Receiver ID. |
* Company Name | The company name of the entity downloading the software |
* Contact Name | The name of the person downloading the software |
Mailing Address Line 1 | First line of the company mailing address |
Mailing Address Line 2 | Second line of the company mailing address |
* City | City of the mailing address |
* State | State of the mailing address |
ZIP | Zip of the mailing address |
Phone | Phone number to reach the contact name |
Fax | Fax number to reach the contact name |
The email address for user |