Instructions for completing the Direct Data Entry (DDE) User ID Request Access form

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Home ► Direct data entry ► Instructions for completing the Direct Data Entry (DDE) User ID Request Access form

Last Modified: 3/19/2024 Location: FL, PR, USVI Business: Part A

These instructions will assist you in completing the Direct Data Entry (DDE) User ID Request Access form.

Instructions for completing the Direct Data Entry (DDE) User ID Request Access form

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 and contact information

• List the legal business name, NPI, tax ID, address, city, state, and ZIP code for the facility.

• List supervisor’s name and email address.

• List the PTAN the user needs access to.

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.

• User’s phone number: Enter the phone number where the user can be reached.

• User’s email address: Enter the user’s business email address. DDE enrollment request details will be sent securely to this email address. The email must comply with these requirements:

• Identify your name and company/organization. (e.g., Jane.Doe@Hospital.org, j.doe@Hospital.org)

• Cannot be a shared emailed address. (e.g., BillingOfficeStaff@Hospital.org)

• Cannot belong to a supervisor/manager. (e.g., MyManagersName@Hospital.org)

• Cannot be a private email address. (Gmail, Yahoo, Verizon, AOL, etc.)

• If you cannot meet these email requirements, please provide a detailed explanation in the Processing Details block. This would include email updates due to a recent name change or updates due to a reorganization or change of ownership.

• For "Remove Access" requests only: Provide the email of the person requesting the access removal.

• Signature: Signature of person whose name appears in the user name field.

• User contact information: phone number and email of user requesting access.

• User ID: Enter the existing user ID.

• PIN: Enter a four-digit numeric PIN (typically the last four digits of the user’s SSN or employee number) to be used for password resets.

Processing Details

• Provide any specific processing details in this block. Explanations regarding name change/email address/etc. should also be listed in this box.

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.

• If the new user ID request is for a new machine user ID, enter the name of machine as first name and “Machine” as last name in the user name field.

• 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.

• Remove PTAN: Select this option to remove PTANs that are no longer needed but the ID is still needed to access other PTANs.

• Add Puerto Rico/U.S. Virgin Islands Workload: Select this option to add Puerto Rico/U.S. Virgin Islands 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 Full: Select this option to change a user’s access to full.

• Add PTAN to ID: Select this option to add additional PTANs to an existing user ID issued by First Coast.

• To Add PTAN to an existing machine ID, enter ‘Machine’ in the last name field and the machine ID in the first name in field.

• Name Change: Select this option to change the user’s name.

• Note: this cannot be used to transfer an ID to a different person. This is only used in the event of a name change.

• User Location: Indicate whether the user the ID is for is located outside of the United States. If you, you must also complete the Out of Country/Offshores Users section.

Attestation

The authorized official is the individual that has 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.

Required signature

• Sign, Date, and Print Name and Title of Authorized Official. Only wet or electronic signatures are accepted. Electronic signatures must show the date and time the form was electronically signed. The signature date of the form must not be more than 30 days prior to the user’s signature if electronically signed.

Note: All forms are processed in the order in which they are received. The submitter will receive a fax/letter if the form cannot be processed or a confirmation letter and instructions to set up/reset the user’s password (as appropriate). Failure to submit all pages may result in your application being returned.

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.