Fillable Direct Data Entry (Dde) User Id Access Request Form (Page 3 of 3) in pdf

DDE user ID Compliance Statement and Authorized Official Signature:

FIRST COAST SERVICE OPTIONS, INC.

MEDICARE PART A COMPUTER SECURITY ADMINISTRATION

DDE USER ID COMPLIANCE STATEMENT

This DDE User ID Compliance Statement, entered into this ____ day of _________, _____ is by and between First Coast

Service Options, Inc. (hereinafter “First Coast”), located at 532 Riverside Avenue, Jacksonville, Florida 32202 and

__________________ (hereinafter “we” or “Provider”) locate at __________________________________________.

We, the undersigned, hereby request receipt of the DDE USER ID, which will be used to gain access to the First Coast,

Medicare Part A network to perform Medicare Part A Direct Data Entry functions.

We agree to:

1. Be responsible for all activities logged under this DDE USER ID.

2. Not share or exchange this DDE USER ID or password.

3. Report to Computer Security Administration any suspected misuse of the DDE USER ID.

4. Use the system to perform tasks only for First Coast Service Options, Inc. business.

5. Follow established corporate policy as described in the Corporate Computer Information Security Policy.

Non-Compliance with the above is considered to be unacceptable behavior, which will be cause for First Coast to revoke

access to the Direct Data Entry (DDE) system.

In accordance with First Coast Corporate Computer Security Policy, your DDE USER ID is not to be used by

anyone other than yourself. Also, your password is not to be revealed to anyone, including Supervisors and

Managers. This DDE USER ID will remain with you as long as you are employed by the aforementioned facility as

First Coast Computer Security monitors all of your activity. If at any time you believe that someone has used

your DDE USER ID, or someone asks you to reveal your password, contact Medicare Part A, DDE Support, at (888)

670-0940, option 3.

By signing below I certify that I 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. I authorize the above listed entities to communicate electronically with First Coast

Service Options on my behalf. By signing below the provider confirms they have read and agree with the Agreement, the

CMS obligations, and the Attestation sections on page 3 and 4 of this document and above signature requirements.

Authorized Official Signature:

Date:

Name and title of authorize official (Print):

Required field - If missing or invalid, application will be returned.

Complete form, sign and date, and return all pages to:

Email:

Fax: (904) 361-0470

Post: First Coast Medicare EDI

P.O. Box 44071

Jacksonville, FL 32231- 4071

Note: All forms are completed in the order in which they are received. The submitter will receive a fax/email/letter if the form

cannot be processed or a confirmation letter and instructions to setup/reset the user’s password (as appropriate). Both pages

of the completed DDE User ID Compliance Statement form should be submitted. Failure to submit all pages may result in

your application being returned.

Page 3 of 3

Revised July 6, 2016

Direct Data Entry (Dde) User Id Access Request Form Page 3

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