Critical Incident Reporting Access Request Form

Critical Incident Report Access for the Iowa Medicaid Portal Access (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:

I'm authorized to have access to my Organization's Incident Reporting data.

Select this OPTION if just need access to complete an Incident Report.

I am a service worker, case manager, or IHH case manager

Select this OPTION if you are the Provider Administrator for your TAD ID (Organization).

LISTS OF NPI'S ASSOCIATED WITH THIS ACCOUNT


This Iowa Government information system is for authorized use only. Users have no expectation of privacy. Any use of this system implies consent to monitoring of any and all activities associated with its use. Unauthorized or improper use of the system may result in administrative disciplinary action and appropriate civil and criminal penalties under applicable law.
The form will be reviewed and approved or denied and an e-mail will be sent as soon as the process is complete to the address listed on the form. This should take no more than 2 business days. Thank you.

What IMPA role do you require for Critical Incident Reporting?

Reviewer - Can review all previously submitted incidents unique to your organization. Reviewer can also add supporting notes to existing incidents. This role could be someone like a QA specialist within your organization, and this role will NOT have the ability to create a new incident.Reporter - Can submit incidents on behalf of members, and review all previously submitted incidents unique to your organization. Report can also add supporting documents and notes to existing incidents.

Do you want to be an administrator for your group?

Select this option if you want to be an administrator for your group.

Contact Information