Get Qies Mdsepocpbj Third-party Service Bureau User Request

The QIES MDSePOCPBJ Third-Party Service Bureau User Request form serves to designate a third-party service bureau user for your facility or manage access changes. This guide provides clear instructions on completing the form online, ensuring the process is straightforward.

Follow the steps to successfully complete and submit the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Identify the type of request you are making. Select either 'Request to Create New Third Party Personal User ID' or 'Request to Change' based on your specific need.
3. If you are making a request to change, specify the relevant option: MDS Submission, Payroll Based Journal (PBJ), or Electronic Plan of Correction (ePOC). Indicate the Third-Party User's Current Personal ID if applicable.
4. Complete the 'Third-Party User Information' section by entering the user's first and last name, phone number, email address, physical address, and company name.
5. In the 'Facility Information' section, provide the name of the facility, select if it is a state license-only facility, and fill in the Medicare CCN or Facility ID. Include both the facility's physical and mailing addresses.
6. Record the contact person's name, phone number, title, and email address within the facility information.
7. Enter the request date accurately to ensure proper processing of your submission.
8. Once the form is complete, save it as a text file before emailing, or prepare it for fax submission. Ensure that all required fields are filled out to avoid delays.
9. Email the form to help@QTSO.com or fax it to 888-477-7871. Remember to attach the facility letterhead for email submissions and ensure that fax cover sheets contain the facility letterhead.
10. After submission, monitor your email for acknowledgment within 2 business days. If no acknowledgment is received, follow up immediately.
11. Allow 5 business days for your request to be processed and finalized.

Complete your QIES MDSePOCPBJ Third-Party Service Bureau User Request form online to streamline your facility's submission process.