Use this document to request a User ID for the TCM System.  The form must be signed by the LGA Coordinator for your County or City. Users with “LGA Adm” level may create “LGA User” type accounts. The LGA Coordinator must keep this form on file. All other accounts must be created by DHCS.

NOTE: This form contains personal information and must be secured. If you choose to fax, you must inform your TCM Analyst personally before faxing to DHCS so the analyst can monitor the fax machine.

• TCM System User ID Request