CMS-10846 TPA Data Entry Fields

Organization Information
Data Element	Field Notes
Name of Organization
Address
City, State, ZIP
P Number(s)
TIN/EIN Name	Business Name for tax purposes (as registered with the IRS). A W-9 may be required.
Employer/Tax Identification Number (EIN/TIN)
Mailing Address for 1099 Tax Form
Address Line #1
Address Line #2
City, State, ZIP
Financial Institution
Name of Bank
Name of Bank 2
Address
City, State, ZIP
ACH/EFT Coordination Name
ACH/EFT Coordination Phone
Routing Transit (ABA) Number	Must be nine digits.
Depositor Account Number
EFT Type
Bank Account Type

Appendix B. Part D Manufacturer Discount Program Third Party Administrator (TPA)
Data Entry Fields

All fields are required.