User Account Setup

User Account Setup

Set Up Your User Account

Please enter the information below to set up your provider user account by completing Section 1 . To associate to a specific provider agency, choose the appropriate option and then complete Section 2. When you have completed the appropriate sections, click the Submit button.

Section 1 - User Information

First Name :

Middle Initial :

Last Name :

Date of Birth :

Ex: mm/dd/yyyy

Business Email Address :

Address :

City :

State :

Zip Code :

Phone Number :

I understand that state and federal laws require that information regarding persons applying for Medicaid Presumptive Eligibility or ABE programs be safeguarded from unauthorized use or disclosure.

Throughout the course of conducting Medicaid Presumptive Eligibility and ABE applications, confidential personal and demographic data from clients will be collected. I understand that I may not use personal, medical, or demographic client data for any purpose that is not directly related to the fulfillment of my agency's outreach and enrollment responsibilities.

I also understand that I may not disclose personal, medical or demographic client information to any person not directly responsible for ensuring the processing of Medicaid Presumptive Eligibility and ABE applications and/or the delivery of healthcare services to members. Required

Please select the type of user that you are. Required

Hospital Providers

I am a regular user for a provider that is certified to submit a Report of Birth.

I am a regular user for a provider that is certified to submit Health Coverage applications.

I am a regular user for a provider that is certified to submit Hospital Presumptive Eligibility (HPE) applications.

I am a designated agency security administrator for a Hospital that is certified to submit a Report of Birth.

Medicaid Presumptive Eligibility Providers

I am the designated agency security administrator for a provider that is certified to submit Medicaid Presumptive Eligibility (MPE) applications and Family Planning Presumptive Eligibility (FPPE) applications.

I am a regular user for a provider that is certified to submit Medicaid Presumptive Eligibility (MPE) applications and Family Planning Presumptive Eligibility (FPPE) applications.

All Kids Providers

I am the designated agency security administrator for a provider that is certified to submit ABE applications.

I am a regular user for a provider that is certified to submit ABE applications.

Long Term Care Providers

I am the designated agency security administrator for a provider that is certified to upload documents.

I am a regular user for a provider that is certified to upload documents.

Other Providers

I am the designated agency security administrator

Section 2 - Organization Information

Please enter the Provider ID(s) associated with the privilege(s) you have selected above. In order to receive access to a provider location, you must enter a Provider ID that is assigned each of the privileges you have selected. If you need access to multiple Provider IDs, please enter the first ID and then click the 'Add' button to add another ID. If you add a box in error, please click the 'Delete' button to remove it. Your account will need to be approved by a Security Administrator. Once your account is approved, you can log back in and access the locations where you have been approved.

HPE ID:

- -

Provider ID

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