Agreement to Receive Reports Electronically for Medicare Provider:

The Provider listed above will retrieve same Provider's electronic reports from Highmark Medicare Services via the Internet. Highmark Medicare Services will give to the Provider an account to be used for this activity. This account will not be used for any transmission of CMS Privacy Act-Protected Data and other sensitive CMS Information.

By signing this agreement the Provider acknowledges and agrees to protect any assigned Logon ID and associated password from disclosure to or use by any unauthorized persons. However, at the Provider's discretion, the Provider may share the assigned Logon ID and password with any employee or agent as the Provider deems necessary. The Logon ID is being assigned to the Provider and should be handled by the Provider as they would a key to any of the Provider's data. If a Provider representative, who has had access to the Logon ID and password, ends his/her relationship with the Provider, the Provider may notify Highmark Medicare Services to have the password changed, or a new account created.

By signing this agreement the Provider also nullifies any previous agreement signed with Highmark Medicare Services or Veritus Medicare Services concerning electronic distribution of the PS&R Summary Reports.

The Provider agrees to assume all internal costs associated with obtaining access to electronic reports on the Internet including, but not limited to, the costs of personal computers, connections, modems, Internet Service Providers and Internet browser software.

This agreement will remain in effect until either the Provider notifies Highmark Medicare Services or Highmark Medicare Services notifies the Provider that access should be discontinued.

 Please check here if you are filling out this form not because you are a new Medicare provider but because you need to be contacted with your login ID and password. The phone number to contact you at is: __________________________.

If the Provider manages multiple facilities and would like those reports bundled together for a single pickup, please list those facilities here: 

Please return via FAX to Carrie Willkomm (412-544-1870), or, via US Mail to: