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
Integrated Health Home
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