WPS Electronic Data Services External Access Request Form ... 2026

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4.8 out of 5

101 votes

The document is a Family Care MOVEit Account Access Form used to request access for submitting Family Care claim data via the MOVEit secure EDI website. It includes sections for user information, type of request (new account, terminate, modify, or data transfer), and authorization details. The form must be completed and submitted to Wisconsin Physicians Service for processing.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your request.
In the 'Managed Care Organization (MCO)' section, check all applicable boxes for your organization and preferred spreadsheet software.
Fill out the 'EXTERNAL USER INFORMATION' section with your name, address, contact details, and Tax ID Number. Ensure accuracy as this information is crucial for processing your request.
Select the type of request you are making by checking one of the options under 'TYPE OF REQUEST'.
If applicable, complete the EDI AUTHORIZATION section indicating whether access is granted or denied.
Finally, review all entries for completeness and accuracy before submitting your form via mail or fax as indicated at the bottom.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (101 Votes)

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