CLIENT PARTICIPATION NOTICES ACCESS REQUEST

This form is intended to be used by providers to request access to the Client Participation (CP) Notices on the Iowa Medicaid Portal Access (IMPA) system.

TAX ID:

BILLING NPI:

TRANSACTION CONTROL NUMBER:

IMPA USERNAME:

FULL NAME:

EMAIL:

Please check here if you agree to receive future relevant provider information from the Iowa Medicaid Enterprise (IME) using this email address. This email address will not be given out and will not be used for any other purpose.

PLEASE GRANT ACCESS TO THE CLIENT PARTICIPATION LISTING.

Please check this box to indicate request

LIST OF NPI NUMBERS ASSOCIATED WITH THIS ACCOUNT:

I certify that I am the administrator of the Client Participation information for the facility that is signing this document and understand that any false statement, omission or misrepresentation may result in prosecution under state and federal laws.

This form will be reviewed and a decision to approve or deny will be made. An email will be sent when this process is complete to the email address listed on this form. This should take no more than 2 business days.

470-5189 (7/14)

Need assistance with this form?