Direct Data Entry (Dde) User Id Access Request Form Page 2
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Facility and Contact Information
Facility Name:
Contact Name:
Contact email address:
Phone number:
Fax number:
Tax ID#/EIN:
NPI:
Medicare Part A Provider PTAN number(s) (Minimum of one PTAN is required):
(1)
(2)
(3)
(4)
(5)
(6)
Note: If additional access is needed, please include the PTAN numbers on a separate page.
Facility Address:
City:
State:
Zip Code:
*
Type of Request
New User ID
Reactivate ID
Terminate ID
Remove PTAN
Add Puerto Rico Workload
Add Florida Workload
Change Access to Full
Change Access to Inquiry
Add PTAN to ID
User Information (Only one user per application)
*
User Name (First, Middle Initial, Last):
Signature:
(Required unless terminating User ID)
User ID:
(Required unless requesting new User ID)
Pin: Must be 4 digits numeric only
(Required unless terminating User
ID),
*
Type of Access:
Eligibility Only
Full
Inquiry
*
Is the user located outside of the United States?
No
Yes (If yes, you must attached a copy of your network connectivity diagram.)
Page 2 of 3
Revised July 6, 2016
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Parent category: Business