Forms

Medicare Claims Processing System DDE PPTN CSI User Request Form
Note: We've recently converted the PDF version of the Medicare Claims Processing System DDE PPTN CSI User Request form to an electronic form.
Please use this new electronic form going forward for submissions.

Medicare Claims Processing System (MCPS) Submission

Requerido First Name
Requerido Last Name
Requerido Phone Number
Ext.
Requerido User's Email
Requerido RACF User ID
Requerido Access Requested
Requerido State/Jurisdiction requesting Access For
Requerido Facility Name
Third Party Biller Name / Parent Corporation Name
 
Please attach a Third Party Biller authorization / Parent Corporation letter below if you have entered a Third Party Biller Name or a Parent Corporation Name.
 
Requerido NPI
Requerido PTAN
Requerido Is the user located outside of the United States?
Requerido Contact Name
Requerido Phone Number
Ext.
Requerido Title
Requerido Email Address
By signing, individuals agree to the following:
  1. Be responsible for all activities logged under the user ID.
  2. Do not share or exchange the user ID or password.
  3. Report to Noridian User Provisioning staff any suspected misuse of the user ID.
  4. Use the system to perform tasks related to Medicare Part A DDE/Part B PPTN/DME CSI/VPIQ system functions only.
  5. Connectivity with EDI is or will be established for the purpose of accessing the Part A DDE/Part B PPTN/DME CSI/VPIQ application.
  6. By signing this document, the submitter bears the responsibility for the authenticity of the information being submitted and acknowledges all responsibility in regard to the content of the data. This includes data submitted on this form and all supporting documents which may be submitted with the request.
Requerido Signatory Name
Requerido Name
Requerido Title
Requerido Today's Date