CMSNet Access Request-MDS/OASIS/ASPENWeb Revision Date: 03/04/2013
CMSNet (Verizon) Access Request
for MDS (NH), OASIS (HHA) and ASPEN Web Users
Please complete this form electronically, print, and sign hard copy to submit
Type of Request
Create New Access Remove Access Update Access
Existing User ID:
Are you replacing someone? Select both Create New Access and Remove Access
Provider/Facility/Agency Name:
Provider Information
Facility ID (N/A for ASPEN Web):
Existing Provider New Provider
Provider Status (select one):
ASPEN WebOASIS (HHA)MDS (NH)
Type of Provider (select one):
Remove User Access Information
User's Name: (Last, First, MI)
Extension:User's Phone Number:
User's E-mail Address:
New User's Name: (Last, First, MI)
Mailing Address:
Work Phone Number: Extension:
Work E-mail Address:
Signature: Date:
New User Access Information
Work Fax Number:
States to which you submit MDS or OASIS data: (N/A for ASPEN Web)
Submit to:
CMSNet (Verizon) Help Desk
Fax: (803) 935-0194
Phone: (888) 238-2122
E-mail: mdcn.mco@palmettogba.com
QTSO Help Desk
Fax: (888) 477-7871
Phone: (888) 477-7876
1501 50th St, Suite 200
West Des Moines, IA 50266
MDS/OASIS USERS Send to: ASPEN Web Users Send to:
Fax cover sheet must contain letterhead and must be sent from a provider/business fax machine
