Iowa Medicaid Enterprise:

Treo Dashboard & Health Risk Assessment Access Request Form

Organization Information

Clinic or Office Name:

If you are requesting an HRA code for the clinic or office, please include the name or DBA title.

TAX ID:

In some cases the Provider TAX ID is also their SSN.

STREET ADDRESS

Enter the street address for your provider organization

CITY

STATE

Enter the 2 digit postal code for your state

ZIP CODE

MEDICAID MEMBER#: (Provide to us just ONE of your current medicaid member info for cross checking)

This is the 7 digit State ID number for one of the members on the patient listing

17 Digit Transaction Control Number (TCN) from a claim paid in the last six months

The TCN is available on the Remittance Advice or by contacting IME Provider Services

Contact Information Of Person Completing This Form

Full Name:

First Name

Last Name

Title

Enter your role within the organization. (office/clinical manager, etc)

Phone #:

(

)

Ext:

EMAIL:

Enter the email address for the individual requesting access. The email address supplied will be your username and the method of communication from Treo

Dashboard Access:

ACOTax IDBilling NPIIndividual NPI

Dashboard Access Only - Please indicate the ACO Name, Tax ID number, Billing NPI number or Individual NPI number requesting access for:

AssessMyHealth Access Code:

I am a provider requesting an access code to AssessMyHealth *Only one HRA access code per username.I am a manager requesting access to AssessMyHealth survey results for providers.

If requesting manager access to HRA results please include the established five character HRA Code utilized by your organization.

Certification Statement

Please certify that each of the statements below are true and accurate by selecting each box. Each statement must be certified for the access to be granted.

I authorize the Iowa Medicaid Enterprise (IME) to verify the information submitted on this form.I ceritfy that I am the individual practitioner or representative and that I have the right to access the patient information contained on this secure site.I understand that if I terminate any agreement with the IME or my employer then it is my express responsibility to terminate my access to this site effective immediately.


The form will be reviewed and approved or denied and an email will be sent, when the process is complete, to the address listed on the form. This should take no more than two business days. The Iowa Medicaid Enterprise may need to contact the person completing this form for additional information. Thank you.

*Please be advised if you do not have a Value Index Score there is no data available for tracking purposes on the Dashboard tool. Please contact Provider Services with questions at imeproviderservices@dhs.state.ia.us Click here to name this section

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