Fiscal Intermediary Shared System (FISS) Enrollment Application

State

When requesting access for multiple states, only one FISS application should be submitted. In this scenario, please choose only one state in the drop down menu below.

Choose a State... Arkansas Colorado Delaware Louisiana Maryland/DC Mississippi New Jersey New Mexico Oklahoma Pennsylvania Texas WPS Legacy

Requester's Information

Who does this RACF ID belong to?

First Name *

Last Name *

If you have gone through a recent name change, please provide an explanation for the name update in the "Processing Details" block below.

Telephone Number *

Requester's Fax Number *

You may receive an encrypted email when your application has been processed. The passphrase to open this email will be faxed to this number.

Work E-Mail Address *

For "Remove Access" requests ONLY: Provide the e-mail of the person requesting the access removal.

This must be your business email address and comply with these requirements:

• Identify your name (e.g. Jane.Doe@Hospital.org, j.doe@Hospital.org)
• Identify your company/organization (e.g. Jane.Doe@Hospital.org)
• CANNOT be a SHARED emailed address (e.g. Billing@Hospital.org)
• CANNOT belong to a supervisor/manager (e.g. BillingOfficeManager@Hospital.org)
• CANNOT be a private email address (Gmail, Yahoo, Verizon, AOL etc.)

If you cannot meet these email requirements, please provide a detailed explanation in the "Processing Details" box below. This would include email updates due to a recent name change.

Supervisor's Full Name *

Supervisor's Phone Number *

Requester's Location

City

State

Zip

Requester's Country

Is this user located outside of the United States? *

Yes No

Third Party Information

Is this request for a Third-Party Biller? *

Yes No

Active User?

Do You Currently Have an active FISS RACF ID? *

Users with an existing FISS RACF ID cannot request additional IDs. If you had a RACF ID assigned to you and it is currently inactive, please list that ID in the box below. If you do not remember your RACF ID, just key the word 'Inactive'.
Yes No

Type of Request

How can we help you?

Select One... New User - Create a new RACF ID Add PTAN(s) to my Existing Logon ID Add FISS access to my existing HIQA access Remove Access Reinstate an inactive RACF ID Other Request

By submitting this form you are agreeing to the following:

• I agree that I have read and completed this application in accordance to CMS Security policy.
• I understand the responsibility to protect and maintain the confidentiality of the data.
• I also understand that if the Medicare data obtained from the FISS is mishandled in any way, I will be held responsible in accordance with Medicare requirements.
• I agree that Novitas Solutions can add my email address indicated above to the general email list to receive electronic notifications.
• I understand that if I do not wish to receive email notifications, I can unsubscribe at any time on the Novitas Solutions website.
• I agree that this unique ID will not be used by anyone other than the person to whom it is assigned and that I may be held legally responsible for any disclosure of the ID.

I have read the above agreement and attest to the truth of all information submitted herein.

IMPORTANT: BEFORE YOU CLICK SUBMIT, PLEASE PRINT THIS PAGE (YOUR COMPLETED FORM) IF YOU WOULD LIKE TO MAINTAIN A COPY FOR YOUR RECORDS!