DEPARTMENT OF HEALTH & HUMAN SERVICESProgramSupportCenter

Post Office Box 6021

Rockville, Maryland 20857

Division of Payment Management

Payment Management System Access Form

***This form must be competed in its entirety in order to be processed***

Please print or type

Action(s) Requested: (check all that apply)

Establish New User Access

 Change Existing User Access: Current PMS Username______

Update Existing User Contact Information: Current PMS Username______

 Deactivate User Access: Current PMS Username if not known,print or type first and last name of person to be deactivated and complete sections 1, 2, and 5 below______

1.Name of Institution/Organization:______

2.Payee Identification Number(s) (PIN) if not known, list EIN:______

Is the action requested for all accounts associated with this PIN(s)? Yes No

3.Request to Establish/Change UserAccess or Update Contact Information for:

Name (Please Print): ______

Title:______

Telephone #:______

E-Mail Address: ______

Mailing Address: ______

______

4.Type of access requested for user. Please select one in each column, if applicable.

Payment Requests and InquiriesFederal Financial Report (FFR)

Fax to:Anthony Holland @ 301/492-4581 or 4571 – No Cover Letter Required

If multiple forms, please fax each one separately

Payment Requests and Inquiries  FSR Preparer Only

Inquiry Only  FSR Certifier Only

 FSR Preparer and Certifier

 FSR View Only

5. Supervisor’s Approval of requested action (recipient organization authorized representative)

If you are the highest ranking person in your organization, please sign your own form.

Supervisor Name (Please Print):______

Supervisor’s Signature:______

Supervisor’s Title: ______Supervisor’s Telephone Number: ______

DPM Payment Management Access Form Information

Action Requested Section

  • Establish New User Access: Individual has never been set-up in PMS
  • Change Existing User Access: Individual is changing current profile information (Email, phone, etc.)
  • Update Existing User Contact Information: Individual is adding a PMS Account Number to an existing username
  • Deactivate User Access: Individual should be removed from PMS Access

Type of access requested for user Section

  • Payment Requests & Inquiries: This person is responsible for requesting funds and performing various queries.
  • Inquiry Only: This person will be allowed to perform queries only.
  • Preparer: The person that is responsible for entering data on the Financial Status Report (FSR)
  • Certifier: The person that will provide the electronic signature on the FFR-FSR. This person should be someone that is authorized to sign financial documents for your organization.
  • Preparer/Certifier: This person has privileges to prepare and certify the FFR-FSR.

Form must be submitted for each individual who needs access or profile must be updated in the Payment Management System. The DPM Payment Management Access Form must be competed in its entirety in order to be processed.

Fax to:Anthony Holland @ 301/492-4581 or 4571 – No Cover Letter Required

If multiple forms, please fax each one separately