Form Dhcs 4517 - California Provider Electronic Data Interchange (Pedi) Account Request - Health And Human Services Agency

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State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
Fax: (916) 440-5346 or
Submit Form:
PROVIDER ELECTRONIC DATA INTERCHANGE
Scan and email:
cmshelp@dhcs.ca.gov
(PEDI) ACCOUNT REQUEST
Contact the CMS Net Help Desk
Questions?
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is to be used by providers and health plans to request access to requests for service/service authorization
information in PEDI. When the “Add” option is selected the user will be assigned a new User ID and temporary
password. The form is also to be used to request modification or deactivation of a user ID. Please type or print
legibly.
Provider Facility/Plan Name:
Select
Phone
Name (Last, First)
Email Address
Position Title
One
(999)999-9999
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Add
Modify
Delete
Phone:
Liaison’s Name (Print):
Date:
Liaison’s Name (Signature):
DHCS 4517 (05/13)
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