Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill out the 'Date of Request' field at the top of the form. This is the date you are submitting the request.
3. Complete the 'Managed Care Organization (MCO)' section by checking all applicable options for the organization you are associated with.
4. In the 'Spreadsheet Software' section, select the software you will use for submission by checking the appropriate boxes, such as Excel or Open Office.
5. Provide the 'External User Information' by filling in your name, street address, city, state, zip code, email address, and contact phone number, as well as the name of your practice and tax ID number.
6. In the 'Type of Request' section, mark the appropriate option for your request (New Account, Terminate Account, Modify Account, or Request data transfer). This section is for WPS use only.
7. For the 'EDI Authorization' section, ensure to check whether access is granted, denied, or pending. The decision will be completed by the EDI move-it administrator.
8. If applicable, have the EDI move-it administrator, EDI manager, and controller of data sign and date the form where indicated.
9. Once all sections are completed, review the information for accuracy. Then, you can save changes, download the form, print, or share it according to your needs.

Complete your forms online today to ensure you receive the necessary access for submitting Family Care claims.