Remittance Advice Provider Access Request Form

Organization Information

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

An NPI that has been verified with IME and is associated with the tax id provided. The NPI entered must match an NPI that has appeared on a remittance advice statement for this tax id. NPIs for treating-only providers who are connected to groups cannot be used to create an account for a local administrator.

A transaction control number (TCN) from a PAID claim within the last eight weeks. The claim must be associated with the NPI entered above.

Please enter the USERNAME that you created on the IMPA Portal:
Contact Information Of Person Completing This Form

First Name
Last Name


Select this OPTION if you are the Provider Administrator for your TAD ID (Organization).

The form will be reviewed and approved or denied and an e-mail will be sent as soon as the process is complete to the address listed on the form. This should take no more than 2 business days. Thank you.