DHS COVID Tracking - User Change Request

Use this form to request a new user to respond on behalf of your organization in the DHS COVID Tracking Tool. Once submitted, the new user will receive an email notification that their account is active in the tool. This process takes a few business days to complete.

Required fields are denoted with an asterisk (*).

User Information

Which type of reporting in the COVID Tracking Tool will this user be performing?* Which type of reporting in the COVID Tracking Tool will this user be performing?*
First Name*
Enter the first name of the user that needs to be provisioned in the tool.
Last Name*
Enter the last name of the user that needs to be provisioned in the tool.
Email Address*
Enter the email address of the user that needs to be provisioned in the tool.
Commonwealth Business Partner ("b-") ID
If the user has a Commonwealth Business Partner ID, please enter it. If the user does not have an existing ID, leave this field blank.

Facility/Provider Information

Please enter the following identifying information of the facility/provider that the user will be reporting on behalf of. Either a License Number, Facility ID, or MPI is required.

Select the DHS program office that this facility/provider is associated with and/or licensed by.* Select the DHS program office that this facility/provider is associated with and/or licensed by.*
Facility/Provider Name*
Enter the legal name of the facility/provider that the user will report on behalf of.
FEIN*
Enter the 9-digit FEIN of the facility/provider that the user will report on behalf of.
License Number
Enter the license number of the facility that the user will report on behalf of.
Facility ID
Enter the Facility ID # of the facility that the user will report on behalf of.
MPI
Enter the 9-digit MPI (Master Provider Index number) of the facility that the user will report on behalf of.
Service Location Code
Enter the Service Location Code of the facility that the user will report on behalf of.

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