Form Cms-20037 - Application For Access To Cms Computer Systems
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1
2
3DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
EUA WorkFlow Request No.
APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS
1. TYPE OF REQUEST
:
(Check only one)
NEW
CERTIFY
(Issue a CMS UserID)
(Due date: _____/__________)
mo
yr
USERID
CONNECT/DISCONNECT
CHANGE USER INFORMATION
(Note new info)
(Capital Letters)
(Add/remove access authorities)
DELETE (Remove CMS UserID from all CMS systems)
2. USER INFORMATION
CMS Employee
Federal Govt – Centers for Disease Control
Medicare Advantage / Medicare Advantage with
& Prevention
Prescription Drug / Prescription Drug Plan / Cost
Federal Govt – Commission Corps
Contracts – Using HPMS Only
Federal Govt – Dept of Health & Human Services
Medicare Advantage / Medicare Advantage with
Federal Govt – HHS – OMHA
Prescription Drug / Prescription Drug Plan / Cost
Federal Govt – Dept of Justice
Contracts – Using Other Systems
Federal Govt – Dept of Veterans Affairs
CITIC Contractor
Federal Govt – Government Accountability Office
Program Safeguard Contractor
Federal Govt – General Services Administration
Medicare Contractor/Intermediary/Carrier
Federal Govt – Internal Revenue Service
Contractor (non-Medicare contract with CMS)
Federal Govt – Office of General Counsel
Researcher
Federal Govt – Office of Inspector General
Quality Improvement Organization
Federal Govt – Railroad Retirement Board
End-Stage Renal Disease Network
Federal Govt – Social Security Administration
State Agency (State of _______________________)
Federal Govt – Other:
Federal Govt – Baltimore HR Center
Other:
First Name
MI
Last Name
(As you want it published)
(As you want it published)
Company/Organization/Department Name
Mailing Address
(Include Suite/Mailstop)
City
State
ZIP Code
Office Telephone
Company Telephone
E-Mail Address
(Include Extension)
(If different)
IF CMS EMPLOYEE Org Name/Admin Code
Are you a Manager?
Yes
No
IF ONSITE AT CMS LOCATION CMS Region/Facility (Check One)
R4 (AFC) Atlanta
DC (HHH) DC
R10 (BLNCH) Seattle
R9 (HWTHRN) San Francisco
CO (CENTRAL) Central Office
R1 (JFKBOS) Boston
R5 (CHIICB) Chicago
R2 (JKJNYC) New York
DC (COHEN) DC
CO (LBDCO) Central Office
R6 (DAL1301) Dallas
CO (NORTH) Central Office
R8 (DENCSB) Denver
R3 (PHIPLB) Philadelphia
R7 (FOBKAN) Kansas City
CO (SOUTH) Central Office
Other _____________________________
Mail Stop
Desk Location
Form CMS-20037 (06/10)
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Parent category: Medical