DOCUMENT(S) UPLOAD ACCESS FORM

 ORGANIZATION INFORMATION

Please enter the Tax ID number for your organization. Sometimes the Tax ID is the SSN
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
Please enter a 17 digit TCN available on your remittance advice. If you do not bill the IME please enter N/A.

CONTACT INFORMATION OF PERSON COMPLETING THIS FORM