Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System

This security form allows providers with existing IMPA usernames to gain access to the Document Upload Application on the IMPA System.

Organization Information

TAX ID: *

Please enter your Tax ID number. In some cases the Provider TAX ID is also a SSN.

BILLING NPI: *

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. If you are a service worker or case manager enter N/A

IMPA USERNAME: *

Please enter the USERNAME that you created on the IMPA Portal:
https://secureapp.dhs.state.ia.us/impa/

Contact Information Of Person Completing This Form

Full Name: *

First Name

Last Name

Phone #: *

( )

EMAIL: *

Provider Type (Please select from the drop down menu) *

470-5417 (07/16)

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