Get 470-5201 Qualified Entity (qe) Medicaid Presumptive Eligibility Portal (mpep) Access Request Form

Filling out the 470-5201 Qualified Entity Medicaid Presumptive Eligibility Portal Access Request Form is essential for Qualified Entities seeking access to the Medicaid Presumptive Eligibility Portal. This guide provides clear and supportive instructions to assist users in completing the form online.

Follow the steps to successfully complete the access request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the name of the Qualified Entity (QE). Ensure that the name is spelled correctly and represents the organization requesting access.
3. Next, fill in the full name of the user submitting the request. This should be the name of the individual responsible for managing the access.
4. Provide a valid phone number where the user can be reached for any follow-up questions regarding the request.
5. Enter a reliable email address for the user. Check the box if you agree to receive future relevant provider information from the Iowa Medicaid Enterprise (IME). Rest assured that this email will be kept confidential.
6. Indicate which groups you are qualified to make presumptive Medicaid eligibility determinations for by checking the appropriate boxes. Options include Pregnant Women, Children, Breast and Cervical Cancer Treatment, among others.
7. State whether you are a qualified entity for more than one organization by selecting 'Yes' or 'No' depending on your situation.
8. Confirm that you have viewed the necessary webinar training by checking 'Yes' or 'No.' This training is a requirement for accessing the portal.
9. Indicate your agreement with the terms stated in the Memorandum of Understanding (MOU) by selecting 'Yes' or 'No.' It is important to understand these terms.
10. Provide your signature and date in the designated area. Verify that you have read the certification statement, which affirms your authority to make presumptive eligibility determinations.
11. Once all sections have been completed, you can save changes to the form, download a copy for your records, print it, or share it as needed.

Start completing your Medicaid Presumptive Eligibility Access Request Form online today.