By submitting this form, you are requesting access to Fidelis Care’s electronic file transfer system in order to trade data electronically with Fidelis Care, which will include data governed by HIPAA. This account is to be used only by the assigned individual to conduct business with Fidelis Care in the file transfer system. The account credentials are not to be shared or used by anyone other than the user listed on this form.

In order to keep your data secure, it is the responsibility of each provider to inform Fidelis Care if users with access are no longer authorized, contracted with or employed by you. The access will be revoked upon notification. Additionally accounts that are inactive for 180 days or more will be expired. If the account is still needed and valid please contact the support team to have the account activated and password reset.

This form may be used for the purpose of enrollment of a user or to de-provision account access for any user. Each individual user who will need access to the Managed File Transfer system will need to have a form filed listing their individual information (separate submission for each person).

Fidelis Care will follow up periodically recertify accounts to confirm this access is still accurate and any individuals with access are still authorized to represent the provider.

For details about any particular field in the form below, please hover over the required field for a brief description.

By submitting this form, you are requesting an update to an existing account on the Fidelis Care electronic file transfer system. This account has access to trade data electronically with Fidelis Care which includes data governed by HIPAA.

This account is to be used only by the assigned individual to conduct business with Fidelis Care in the file transfer system. The account credentials are not to be shared or used by anyone other than the user listed on this form.

For details about any particular field in the form below, please hover over the required field for a brief description.

By submitting this form, you are requesting to remove an existing account from the Fidelis Care electronic file transfer system. This account has access to trade data electronically with Fidelis Care, which includes data governed by HIPAA. Once this account is deactivated, the account will no longer have access to trade data electronically.

For details about any particular field in the form below, please hover over the required field for a brief description.

Electronic Remittance Advice Information

In this section you can choose which level you want to aggregate your data by.

Submission Information

Additional Information