Are you applying for an IMPA Access Request Form? This can be a complicated process, but don’t let it overwhelm you. With the right information and resources, completing your request should be a breeze. Keep reading to learn all about the IMPA Access Request Form and how to complete it successfully so that you can get access to the services you require.
| Question | Answer |
|---|---|
| Form Name | Impa Access Request Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | impa national iowa get, form impa, health home request, impa iowa |
Health Home IMPA Access Request Form
Please return this completed form to: Provider Services Unit, Iowa Medicaid Enterprise P.O. Box 36450 Des Moines, IA 50315 or fax to (515)
Health Home Information: (Enter the Taxpayer ID and National Provider Number enrolled with Medicaid as provider type 71)
1.Taxpayer ID:
2.National Provider Identifier:
Contact Information: (Enter the contact information for the staff person who will be responsible for patient enrollment into the Health Home)
Name:
Phone Number:
Email Address:
IMPA User Name:
The utilization of IMPA (referenced in Section 4 of the Health Home Provider Agreement) involves a resource (Health Home staff member) that will login and request Health Home enrollment of qualifying patients from the practice.
This form will be reviewed and approved or denied and an
Signature:
Date:
Questions in completing this form contact: Iowa Medicaid Enterprise Provider Services Unit at (800)