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J15 DDE PPTN Application/Reactivation

* Required

Request Information

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


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

If outside US, please send a copy of network connectivity diagram to 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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