EVV vendors are required to complete this form in order to initiate the testing process to send ICNs to be included on 837 files generated by CareBridge (Fields 101-104 on the CareBridge Data Integration Specification) Prior to completing this form, vendors should review the ICN technical specification and testing guide under "Additional Documents for Third-Party Vendors" on the Integration site here: http://evvintegration.carebridgehealth.com/