Get form impa 2012-2024

Health Home IMPA Access Request Form Please return this completed form to Provider Services Unit Iowa Medicaid Enterprise P. 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 e-mail will be sent as soon as the process is completed to the address listed on the form. Signature Date Questions in completing this form contact Iowa Medicaid Enterprise Provider Services Unit at 800 338-7909 or 515 256-4609 Option 2. O. Box 36450 Des Moines IA 50315 or fax to 515 725-1155 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 e-mail will be sent as soon as the process is completed to the address listed on the form* Signature Date Questions in completing this form contact Iowa Medicaid Enterprise Provider Services Unit at 800 338-7909 or 515 256-4609 Option 2. O. Box 36450 Des Moines IA 50315 or fax to 515 725-1155 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. .