YOUR PRACTICE LETTERHEAD - Florida Department of Health
Send completed form by fax or email to the following:
CMS Provider Management
Fax: (850) 487-1279
Email: cmsproviderhelp@doh.state.fl.us
Password Request Form
To allow a designee to use a provider’s User ID and Password for the CMS Provider Management System, please use the following letter template on your practice letterhead and submit to CMS Provider Management.
(Date)
Children’s Medical Services
4052 Bald Cypress Way
BIN A-06
Tallahassee, FL 32399-1707
P: 850-245-4215
F: 850-487-1279
To Whom It May Concern,
I am due for re-credentialing with Children’s Medical Services and give permission to Children’s Medical Services Provider Management to forward my User ID and Password to our practice Credentialing Manager, (insert name here). This information will be used to complete my application for re-credentialing. The coordinator can be reached at, (phone number) and I can be reached at (phone number) should you have any questions about this request for information.
________________________________ ________________________________
Provider’s Signature (stamps not accepted) Provider’s Medical/Dental License
________________________________ ________________________________
Provider’s Printed Name (with middle initial) Date
................
................
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