DIRECT DATA ENTRY (DDE) USER ID ACCESS REQUEST FORM
INSTRUCTIONS
Forms that are not legible or filled out incorrectly will be returned. It can take up to 30 days to process application from the
date a correct form is received.
Facility Information
List the Facility name, NPI, Tax ID Address, City, State and ZIP Code for the Authorized Official.
List the Provider number (also referred to as PTAN, Oscar, or Medicare number) the user needs access to.
Type of Request
New User ID: Select this option if the user has never been assigned a User ID or was previously assigned a User ID but
does not remember the User ID.
Reactivate ID: Select this option to reactivate a User ID that has been deactivated due to non- usage. The ID can only
be reactivated for the user the ID was originally assigned to.
Terminate ID: Select this option to terminate User IDs that are no longer needed.
Add PTAN to ID: Select this option to add additional PTANs to an existing User ID issued by First Coast
Change Access to Full: Select this option to change a user’s access to full.
Add PR Workload: Select this option to add Puerto Rico workload to a User ID created by another MAC.
Add FL Workload: Select this option to add the Florida workload to a User ID created by another MAC.
Change Access to Inquiry: Select this option to change a user’s access from “Full” to “Inquiry”.
Remove PTAN: Select this option to remove PTANs that are no longer needed but the ID is still needed to access other
PTANs.
User Information - Only one user request per form.
User Name: Enter the name of the person who will be accessing the system or is being terminated.
Signature: Signature of person whose name appears in the User Name field.
User ID: Enter the existing User ID.
PIN: Enter a 4-digit numeric PIN (typically the last 4 digits of the users Social Security or Employee Number) to be used
for password resets.
Type of Access: Select one of the following:
Full access: Provides the ability to edit claims and access CWF.
Inquiry access: Provides the ability to view claims only and access to the Common Working File (CWF).
Eligibility Only: Provides the ability to access ELGA or HIQA only.
Is the User located outside the United States?
Select “No” if the user is located inside the United States.
Select “Yes” if the user is located outside of the United States.
If you select “Yes” you must provide a copy of your network data connectivity diagram.
Authorized Official Signature
The Authorized Official is the individual that have been appointed an authorized individual to whom the provider has granted
the legal authority to enroll it in the Medicare Program, to make changes and/or updates to the provider's status in the
Medicare Program (e.g., new practice locations, change of address, etc.), and to commit the provider to abide by the laws,
regulations, and the program instructions of Medicare.
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Revised July 6, 2016