DOCUMENT(S) UPLOAD ACCESS FORM
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
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.
Critical Incident Reporting
Health Risk Assessment
Electronic Billing Requirements
CONTACT INFORMATION OF PERSON COMPLETING THIS FORM
I am the administrator, please grant me access to upload documents.