Free Income Maintenance Quality Assurance (IMQA) Web Request, HCF 16083 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16083 (07/06)

STATE OF WISCONSIN

INCOME MAINTENANCE QUALITY ASSURANCE (IMQA) WEB REQUEST
(Please read the information on the next page for instructions.) 1. Please check one of the following: Activate User ID for access to the IMQA Web Delete User ID for access to the IMQA Web Change (Profile, User Name, Social Security Number)
Effective Date

Please fill in the following information. All items must be completed.
2. User ID (from DWD Wisconsin Account Creation screen) 3. User Name (Last, First, MI)

4. Social Security Number

5. Mother's Maiden Name

6. Agency Name (Do not abbreviate.)

7. Supervisor's Name

8. Supervisor's Telephone Number

9. User's Daytime Telephone Number

10. Profiles Reviewer (Counties complete Number 11) County Read Only Update and Read Statewide (State staff only) Administrator (State staff only) State Read Only (State staff only)

11. County Name(s)

Use of this logon and password provides access to confidential information, which must be safeguarded in accordance with Wisconsin Statutes. The user's signature on this form constitutes acceptance of responsibility for compliance with §49.32(10), §49.32(10m), §49.81, §49.83 and §943.70(2). 12. SIGNATURE ­ User Date Signed

13. SIGNATURE ­ Supervisor

Date Signed

Return this form to your State/County/Tribal/W-2 Agency Security Officer 14. SIGNATURE - State / County / Tribal / W-2 Agency Security Officer Date Signed

15. SIGNATURE - State Security Officer

Date Signed

RESET FORM

Income Maintenance Quality Assurance (IMQA) Web Request F-16083 (07/08)

Page 2

INSTRUCTIONS
1. Check the appropriate box to activate, delete, or change a user ID. Only one box should be checked. For effective date, enter the date the user's ID is to be activated, deleted, or changed. 2. Enter User ID (from DWD Wisconsin Account Creation screen). To create a User ID on the DWD Wisconsin Account Creation screen, follow instructions listed in Section 2 "IMQA Access" of the IMQA Second Party Review Manual http://www.emhandbooks.wi.gov/imqa/Accessing_IMQA/IMQAAccess.htm . 3. Enter the user's name. 4. Enter the user's Social Security Number (SSN). The SSN is one of the unique identifiers used for security purposes. The SSN is voluntary. If SSN is not provided, however, access will be denied, SSN will be kept confidential and not used for any other purposes. 5. Enter the maiden name of the user's mother. 6. Enter the user's agency name. 7. Enter the name of the user's supervisor. 8. Enter the telephone number of the user's supervisor. 9. Enter the user's daytime phone number. 10. Enter the user's profile. See the following for descriptions of each profile: · · · · · Reviewer: Able to view and update only reviews in his/her county. Reviewers in consortiums should indicate all local agencies in consortium on line 11. Read Only-County: Able to view reviews in his/her county only. Administrator: Able to view all counties' reviews and make changes to the review tool (State Staff only). Read Only-Statewide: Able to view reviews from any county (State Staff only). Update and Read Statewide: Able to read and update reviews statewide (State staff only).

11. Enter the county name(s). 12. The user signs in this field. 13. The user's supervisor signs in this field. 14. The user's state, county, tribal or W-2 agency security officer signs in this field. 15. The state DWD security officer signs in this field.

This form must be returned to the user's state, county, tribal or W-2 agency security officer for approval. The user's state, county, tribal or W-2 agency security officer will forward this form to the state DWD security officer. The user will receive a notice when access has been approved.