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J15 DDE PPTN Application/Reactivation

* Required

Request Information

Date: 6/16/2024
Action Requested:*
Line of Business:*

Entity

Entity Type:*
Entity Name:*
Entity E-Mail:*
Entity Phone:* Ext:
Entity Fax:
Entity Address 1:*
Entity Address 2:
Entity City:*
Entity State:*
Entity Zip:*

Note: Entity Address is used to validate Individual Provider information.

Contact Person

Contact Name:*
Contact E-Mail:*
Contact Phone:* Ext:

Providers these users can access (Max 5 per request)

Provider Name* PTAN* NPI*

Users that can access each of the providers listed (Max 5 per request)

Leave Existing ID field blank when applying for NEW RACF ID.

First Name* Middle Initial Last Name* Email* Phone* Existing ID Outside US
Ext:
Ext:
Ext:
Ext:
Ext:

If outside US, please send a copy of network connectivity diagram to CGS.EDI@cgsadmin.com and include your request ID in the subject line of the email.

By clicking this checkbox, you are providing your signature that the above information is accurate and complete.*

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