New Request/Revision to Existing Account: Check the appropriate box. An entity requesting an initial account/password should check the New Request box; an entity that has an existing account and is advising the Department of a change to that account should check the Revision to Existing Account box.

New Request
Revision to Existing Account

Payor/TPA/ASO/Provider Name: Enter name of entity that may use the OPA website.

Payor/Third Party Administrator/Administrative Services Only Organization/Provider Name:

Federal Employer Identification Number (FEIN): Enter FEIN assigned to the entity named above.

Federal Employer Identification # (FEIN):

Operating Certificate # (For providers only): Enter Operating Certificate number assigned by the Department of Health to the entity named above.

Operating Certificate # (FOR PROVIDERS ONLY):

Report(s) being filed electronically (check ALL applicable types): Check all applicable types of reports that your entity will be filing electronically – Public Goods Pool and/or Statewide Assessment.
Public Goods Pool
1% Statewide Assessment (for hospitals only)

By signature below, the Chief Financial Officer or other duly authorized individual of the above named entity authorizes the Office of Pool Administration to assign a secure electronic filing user ID and password to the entity. This information will be mailed directly to the attention of the signer and must remain secured. If an email address is provided, this information will be sent electronically to the email address listed. It is the responsibility of the above named entity to ensure that this information is released only to those individuals requiring knowledge thereof.

Signature: Must be signed by the Chief Executive/Financial Officer and/or Administrator of the entity named above. (Type your full name)

Name/Title/Phone Number (Please Print): Enter name, title and phone number of the person signing above.

Name:

Title:

Phone Number:

Address/City/State/Zip Code: Enter address of the person signing above.

Address:

Address Line 2:

City:

State:

Zip Code:

E-mail Address: Enter e-mail address of the person signing above. This email address will be used to communicate Health Care Reform Act information, including delinquency reporting notifications and periodic legislative updates.

Date: Enter date this form is signed.