Application For Access To CMS Computer System {CMS-20037}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES EUA WorkFlow Request No. APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS 1. TYPE OF REQUEST NEW (Check only one): (Issue a CMS UserID) CERTIFY (Due date: _____/__________) mo yr CONNECT/DISCONNECT (Add/remove access authorities) CHANGE USER INFORMATION (Note new info) DELETE (Remove CMS UserID from all CMS systems) (Capital Letters) USERID 2. USER INFORMATION CMS Employee Medicare Advantage / Medicare Advantage with Prescription Drug / Prescription Drug Plan / Cost Contracts ­ Using HPMS Only Medicare Advantage / Medicare Advantage with Prescription Drug / Prescription Drug Plan / Cost Contracts ­ Using Other Systems CITIC Contractor Program Safeguard Contractor Medicare Contractor/Intermediary/Carrier Contractor (non-Medicare contract with CMS) Researcher Quality Improvement Organization End-Stage Renal Disease Network State Agency (State of _______________________) Federal Govt ­ Baltimore HR Center First Name (As you want it published) Federal Govt ­ & Prevention Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Federal Govt ­ Other: Centers for Disease Control Commission Corps Dept of Health & Human Services HHS ­ OMHA Dept of Justice Dept of Veterans Affairs Government Accountability Office General Services Administration Internal Revenue Service Office of General Counsel Office of Inspector General Railroad Retirement Board Social Security Administration Other: MI Last Name (As you want it published) Company/Organization/Department Name Mailing Address City (Include Suite/Mailstop) State (If different) ZIP Code E-Mail Address Are you a Manager? Yes No Office Telephone (Include Extension) Company Telephone IF CMS EMPLOYEE Org Name/Admin Code IF ONSITE AT CMS LOCATION CMS Region/Facility (Check One) R4 (AFC) Atlanta R10 (BLNCH) Seattle CO (CENTRAL) Central Office R5 (CHIICB) Chicago DC (COHEN) DC R6 (DAL1301) Dallas R8 (DENCSB) Denver R7 (FOBKAN) Kansas City Mail Stop Form CMS-20037 (06/10) American LegalNet, Inc. www.FormsWorkFlow.com DC (HHH) DC R9 (HWTHRN) San Francisco R1 (JFKBOS) Boston R2 (JKJNYC) New York CO (LBDCO) Central Office CO (NORTH) Central Office R3 (PHIPLB) Philadelphia CO (SOUTH) Central Office Other _____________________________ Desk Location 3. WORKLOAD INFORMATION Contract Number(s) (for Medicare Advantage/Medicare Advantage with Prescription Drug/Prescription Drug Plan/Cost Contracts -- Hxxxx, Sxxxx, etc.) Carrier Number(s) (for Medicare Contractors/Intermediaries/Carriers -- 12345) (for Contractors -- CMS-05-0001 : 0001) Contract and Task Number Grant Number (for Researchers) Inter-Agency Agreement Number 4. REQUIRED ACCESSES (See http://www.cms.hhs.gov/mdcn/bmcjcreport.asp for list of available jobcodes) Connect Disconnect Keep Default CMS Connect Disconnect Employee Connect Disconnect (standard desktop & network with CMS e-mail acct) Connect Disconnect Connect Disconnect Connect Disconnect Keep Default Non-CMS Employee Connect Disconnect (standard network access) Connect Disconnect Connect Disconnect Keep ________________ Connect Disconnect Connect Disconnect Keep ________________ Connect Disconnect Connect Disconnect Keep ________________ Connect Disconnect Connect Disconnect Keep ________________ Connect Disconnect Connect Disconnect Keep ________________ Connect Disconnect 5. JUSTIFICATION (If name change, show Old Name =, New Name =) Keep Keep Keep Keep Keep Keep Keep Keep Keep Keep Keep ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ 6. APPROvALS: (See http://www.cms.hhs.gov/mdcn/reqsigchart.pdf for approval info) PROvIDE SIgNATURES bELOW OR APPROvE ONLINE EUA WORKFLOW REQUEST NUMbER REFERENCED ON PAgE 1. Authorization: We acknowledge that our Organization is responsible for all resources to be used by the person identified above and that requested accesses are required to perform their duties. We have reviewed and verified the workload information supplied is accurate and appropriate. We understand that any change in employment status or access needs are to be reported immediately via submittal of this form or EUA WorkFlow request. 1st APPROvER Printed Name CMS UserID 2nd APPROvER Printed Name CMS UserID (CMS Project Officer, CMS Contact, CMS Supervisor, MCIC Contact, etc.) Telephone Number Signature (Not required for CMS employees, BHRC or Commissioned Corps) Date Telephone Number Signature Date APPLICANT: Read, complete and sign next page. Form CMS-20037 (06/10) American LegalNet, Inc. www.FormsWorkFlow.com 2 EUA WorkFlow Request No. APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS Printed Name (As you want it published) Social Security Number Date of Birth CMS USERID PRIvACY ACT STATEMENT The information on page 1 of this form is collected and maintained under the authority of Title 5 U.S. Code, Section 552a(e)(10) (The Privacy Act of 1974). This information is used for assigning, controlling, tracking, and reporting authorized access to and use of CMS's computerized information and resources. The Privacy Act prohibits disclosure of information from records protected by the statute, except in limited circumstances. The information you furnish on this form will be maintained in the Individuals Authorized Access to the Centers for Medicare & Medicaid Services (CMS) Data Center Systems of Records and may be disclosed as a routine use disclosure under the routine uses established for this system as published at 59 FED.REG.41329 (08-11-94) and as CMS may establish in the future by publication in the Federal Register. The Social Security Number (SSN) is used as an identifier in the Federal Service because of the large number of present and former Federal employees and applicants whose identity can only be distinguished by use of the SSN. Collection of the SSN is authorized by Executive Order 9397. Furnishing the information on this form, including your Social Security Number, is voluntary. However, if you do not provide this information, you will not be granted access to CMS computer systems. SECURITY REQUIREMENTS FOR USERS OF CMS COMPUTER SYSTEMS CMS uses computer systems that contain sensitive information to carry out its mission. Sensitive information is any information, which the loss, misuse, or un