Input Sheet for Era/Eft Providers

Input Sheet for Era/Eft Providers

<p> FAMILY CARE MOVEIT ACCOUNT ACCESS FORM</p><p>WPS Electronic Data Services External Access Request Form Secure EDI Website (Moveit)</p><p>Date of Request: ______</p><p>Please complete the required portions of this Request Form in order to receive the necessary access for submission of Family Care claim data via MOVEit. </p><p>Managed Care Organization (MCO) Spreadsheet Software* (Check all applicable below)</p><p> Excel  Open Office</p><p>(Check all applicable below)</p><p> CLTS  COMMUNITY LINK, INC (CLI) formerly CCCW, ContinuUs, and WWC  LAKELAND CARE, INC (LCI)  MY CHOICE FAMILY CARE (MCFC) EXTERNAL USER INFORMATION*</p><p>Name </p><p>Street Address</p><p>City, State, Zip</p><p>Contact Person</p><p>E-Mail Address</p><p>Contact Phone</p><p>Name of Practice</p><p>Tax ID Number EDI Submitter Number (WPS Use Only)</p><p>TYPE OF REQUEST (For WPS Use Only) ______New Account ______Terminate Account ______Modify Account ______Request data transfer</p><p>D:\Docs\2017-12-14\0f8dc64875122facc86272e6e9bbed90.doc Approved by: Jeff Blum Created by Marcia Green on 05/25/2017 Last Revised on 05/25/2017 1 FAMILY CARE MOVEIT ACCOUNT ACCESS FORM EDI AUTHORIZATION – RESPONSIBLE PARTY FOR PRODUCT ACCESS EDI Secure Website (Move-it): (TO BE COMPLETED BY EDI MOVEIT ADMINSTORATOR)</p><p>______Granted ______Denied ______Pending </p><p>Denial Reason: ______</p><p>EDI Move-it Administrator Signature: ______Date: ______EDI Manager Signature ______Date: ______Controller of Data Signature: ______Date: ______</p><p>ACCOUNT CREATED: </p><p>User ID Assigned: ______Level User Assigned: (check one) ______User ______Group Admin (File Admin) ______Sysadmin Group(s) assigned to User (if any): ______Group(s) created to accommodate Request: ______</p><p>An original, faxed or e-mailed copy will be accepted. Please mail or fax your completed agreement to:</p><p>Wisconsin Physicians Service Electronic Data Service P.O. Box 8128 Madison, WI 53708-8128 Fax (608)223-3824 [email protected]</p><p>*REQUIRED</p><p>D:\Docs\2017-12-14\0f8dc64875122facc86272e6e9bbed90.doc Approved by: Jeff Blum Created by Marcia Green on 05/25/2017 Last Revised on 05/25/2017 2</p>

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