Form CMS-10157 CMS-10157.Revised HETS Access Request Form

Access Request for Connectivity to the HIPAA Eligibility Transaction System (HETS 270/271)

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0960. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Organization Information

The Medicare provider/supplier organization that is requesting access to the HETS 270/271 must complete these fields with the organization’s information. If you are obtaining connectivity through a Third Party Vendor, you will be prompted for that information later. Please enter your organization’s information, including the Technical Contact at your organization who will serve as CMS’ primary contact for technical questions about 270/271 testing and usage.

	* all fields are required
Date of Request
Organization Name (Doing Business As):
Organization Physical Site Address:
Organization City, State, Zip Code:
Organization Technical Contact Name:
Organization Technical Contact Phone:
Organization Technical Contact Email Address:

Connectivity Information

1.	Does your site have IP connectivity into the AGNS network?
	Yes No If your answer is YES, please proceed to question 2. If the answer is NO, please exit this site and contact an approved AT&T AGNS reseller to establish a connection to submit 270 transactions and receive 271 responses .When you establish IP connectivity into the AGNS network, re-visit this site to request Access. Please do not use the submit button to exit this web site. A complete list of AT&T AGNS resellers for 270/271 transactions can be found at: http://www.cms.hhs.gov/HETSHelp/ under the ‘Sign Up Now’ Section.
2.	Does your site utilize an existing 270/271 connection via a Third Party Vendor? Third Party Vendors are organizations that have already obtained a Medicare 270/271 connection; these organizations re-sell that connection to qualified Medicare providers. Third Party Vendors may offer a mechanism to create a properly formatted 270 request or may simply act as a conduit to submit 270 requests. These organizations have already established an AT&T AGNS connection; customers of these Third Party Vendors do not need to establish their own AT&T AGNS connection, but must be authenticated as entitled providers before 270/271 access will be granted.
	Yes No If your answer is YES, please proceed to question 3. If the answer is NO, please skip question 3 and proceed to question 4
3.	Please provide the Third Party Vendor contact information. If you do not have this information, please exit this website, obtain the Third Party Vendor information requested below, and re-visit this site to request Access. Please do not use the submit button to exit this web site.
	Third Party Vendor Organization Name:
	Third Party Vendor Technical Contact Name:
	Third Party Vendor Physical Site Address:
	Third Party Vendor City, State, Zip Code:
	Third Party Vendor Phone:
	Third Party Vendor Email Address:
	Your application is now complete. Please review your entries to ensure that all necessary fields are complete and click on the ‘Submit’ button at the bottom of the screen.
4.	What are the AGNS account names (i.e. BXKY, BXSC, CWF3) associated with each customer in this request? (i.e. the AGNS account for the IP connectivity into the CMS central office is 'HCFA').
5.	What is the public IP network address to be routed? Note: CMS network security policy does not allow use of subnet masks or IP ranges; you must supply a specific static IP address(es) to be routed. This must match the public IP address that will arrive at the CMS firewall for authentication and approval. Contact your network administrator or AT&T AGNS reseller if you are not certain what the IP address will be. Sites requesting more than 1 static IP address for routing must provide additional information explaining why additional routes are necessary.
	Your application is now complete. Please review your entries to ensure that all necessary fields are complete and click on the ‘Submit’ button at the bottom of the screen.