user request form pdm by HC121005151549

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									                                                                                                                                                  Commonwealth of Massachusetts
                                                                                                                                            Executive Office of Health and Human Services                                                                                                                                                                                                                                                                                                                       Instructions:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                1.   All non-role fields are required.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                2.   Fill in form, place an "X" in the column with the requested role(s).
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                3.   Save document as YourOrganizationName_MMDDYY
                                                                                                                                                 New User Request & Account Modification                                                                                                                                                                                                                                                                                                                        4.   Email completed form to:
                                                                                                                                                     Form for Virtual Gateway Access
                                                                                                                                                (TYPE INFORMATION DIRECTLY INTO FORM)                                                                                                                                                                                                                                                                                                                                                            VirtualGatewayHelpDeskFaxes@massmail.state.ma.us



                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                PLEASE SUBMIT ONE FORM PER EMAIL
                                                                                                                                    Provider Data Management (PDM)
                                                                                                                                       User Request Form (URF)                                                                                                                                                                                                                                                                                                                                                  Questions? Call EOHHS Virtual Gateway Customer Service
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PHONE                                                                                    800-421-0938
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           TTY                                                                                      617-847-6578

                                                                                                                                                                                                                                                                                                              Financial                                                                                                                                                                                                                                                               Functional
                                                                                                                                                                                                                                                               Provider                                                                         Agency                                                               Provider                                                                                                                                                                Agency                                                                                                                                                                                                                                  Check One




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Area Office Management Staff (Adult Waiver) - Functional
                                                                                                                                                                                                                  PDM Data Entry Administrator - Financial**




                                                                                                                                                                                                                                                                          PDM Provider Reviewer - Financial




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Deactivate Existing User from PDM
                                                                                                                                                                                                                                                                                                                                                                               PDM Qualification Staff - Financial




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Regional Office Management Staff
                                                                                                                                                                                                                                                                                                                PDM Agency Review - Financial




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Deactivate Existing User from
                                                                                                                                                                                                                                                                                                                                                 PDM Cognos User - Financial




                                                                                                                                                                                                                                                                                                                                                                                                                                DDS Application Manager




                                                                                                                                                                                                                                                                                                                                                                                                                                                          Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Functional Qualification




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Modify Existing User




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     the Virtual Gateway
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Qualification
                                                                                       4-Digit PIN*




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   New User
                                                                                        (Personal
           Fir st Nam e               MI               Last Nam e                Identification Number)        MMDD of Bir th               Wor k E-m ail Addr ess                  Wor k Phone #




* Select a 4 digit Personal Identification Number (PIN). The user may be asked to provide this number to identify himself/herself when calling Virtual Gateway Customer Service. It must be 4 numbers (0-9) and be something that can be remembered, but not easily guessed. 1234 and 0000 may not be used.

**The user should not have the PDM Provider Reviewer as well. This role will conflict with Data Entry.**

I HEREBY CERTIFY THAT I AM THE DULY AUTHORIZED ACCESS ADMINISTRATOR FOR MY ORGANIZATION OR AGENCY, AND THAT ALL OF THE INFORMATION I AM PROVIDING TO VIRTUAL GATEWAY OPERATIONS IS ACCURATE AND COMPLETE.



                                                                                                                                                Organization
 Access Administrator Name
                                                                                                                                                 Full Name



     Access Administrator                                                                                                                      Organization ID
        Email Address                                                                                                                             Number



     Access Administrator
                                                                                                                                                     Date
          Telephone




                                                                                                                                                                                                                                                                 PDM URF v5

								
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