INPUT SHEET FOR ERA/EFT PROVIDERS
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WPS Electronic Data Services External Access Request Form
Secure EDI Website (Moveit)
Date of Request: ____________
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.
Managed Care Organization (MCO)
Spreadsheet Software*
(Check all applicable below)
□ Excel
□ Open Office
(Check all applicable below)
□ CLTS
□ INCLUSA formerly COMMUNITY LINK, INC (CLI)
□ LAKELAND CARE, INC (LCI)
□ MY CHOICE FAMILY CARE (MCFC)
EXTERNAL USER INFORMATION*
|Name | |
|Street Address | |
|City, State, Zip | |
|Contact Person | |
|E-Mail Address | |
|Contact Phone | |
|Name of Practice | |
|Tax ID Number | |
|EDI Submitter Number (WPS Use | |
|Only) | |
TYPE OF REQUEST (For WPS Use Only)
______ New Account ______ Terminate Account ______ Modify Account ______Request data transfer
EDI AUTHORIZATION – RESPONSIBLE PARTY FOR PRODUCT ACCESS
EDI Secure Website (Move-it): (TO BE COMPLETED BY EDI MOVEIT ADMINSTORATOR)
________ Granted ________ Denied _________ Pending
Denial Reason: __________________________________________________________________________________
EDI Move-it Administrator Signature: ______________________________________ Date: _______________
EDI Manager Signature __________________________________________________ Date: _______________
Controller of Data Signature: ______________________________________________ Date: _______________
ACCOUNT CREATED:
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: ___________________________________________________
An original, faxed or e-mailed copy will be accepted. Please mail or fax your completed agreement to:
Wisconsin Physicians Service
Electronic Data Service
P.O. Box 8128
Madison, WI 53708-8128
Fax (608)223-3824
EDI@
*REQUIRED
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