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Facility Access Request/Change Application

This form is used by facilities requesting facility role access to the TMU testing platform, It may also be used if there is a change in the person responsible for this role. (payments/reports) This is not the same as a MAP 414 change. This is only system access approval.

Name

Email

Director of Nursing

Fax

Phone

Alt Phone

Administrator

Approval Number

Medicaid Number

Medicare Number

Address

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Discipline Select the discipline type you are applying for.

Affidavit

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.