DOCUMENT(S) UPLOAD ACCESS FORM
ORGANIZATION INFORMATION
TAX ID:
Please enter the Tax ID number for your organization. Sometimes the Tax ID is the SSN
x
BILLING NPI:
Please enter your 10 digit NPI that has been verified with the IME. If you are a service worker or case manager enter N/A
x
TRANSACTION CONTROL NUMBER:
Please enter a 17 digit TCN available on your remittance advice. If you do not bill the IME please enter N/A.
x
IMPA USERNAME:
ACCESS REQUEST
Please select...
Critical Incident Reporting
HCBS Assessment
Health Risk Assessment
Medicaid AR
Electronic Billing Requirements
Health Home
CONTACT INFORMATION OF PERSON COMPLETING THIS FORM
FULL NAME:
PHONE #:
EMAIL:
I am the administrator, please grant me access to upload documents.
Yes
Contact Information