IMMEDIATE ACTION REQUIRED ProviderOne ID: PROVIDER SUPPLEMENTAL INFORMATION REQUEST The Department of Social and Health Services has transitioned to its new claims payment system called ProviderOne. Completion of this form is necessary to designate your Security Administrator who will be issued a Username and temporary password to access ProviderOne. Your Security Administrator is responsible for overseeing access to ProviderOne for your staff, setting up additional users, and user profiles in your assigned Domain (ProviderOne ID). PROVIDERONE SECURITY ADMINISTRATION Name of Security Administrator (First, Last, Middle Initial) Security Administrator’s Date of Birth Physical Address (Street) (City) (State) (Zip) Business Name Security Administrator’s Email Address National Provider Identifier (NPI) Security Administrator’s Phone Number Federal Tax ID (FEIN) Providers must respond within seven (7) days of receiving this request. Fax this form back to IT Security at (360) 586-0702 or mail to Provider Enrollment, PO Box 45512, Olympia, WA 98504-5512. ACCESS TO PROVIDERONE: Security administration Username and password will be sent to the email address listed above. SECURITY PROFILES: Once you receive your security information, you will need to login to ProviderOne using your “EXT Provider Security Administrator” Profile. In ProviderOne, click on “Maintain Users” under “Admin” and set up accounts and profiles for your users. To access ProviderOne go to https://www.waproviderone.org. For more information and training on user profiles, visit the website below. UPDATING PROVIDER INFORMATION IN PROVIDERONE Once you have received your login information, you may review and update information in your provider file. Log in at https://www.waproviderone.org with the “EXT Provider File Maintenance” or “EXT Super User” Profile. In the Provider Portal, click on “Manage Provider Information” to review your provider file. Important steps to review are: • Address Information • Payment Detail; and • Electronic Data Interchange Information if you plan on submitting HIPAA batch files • If updates are made in the Provider File Business Process Wizard, please make sure you go to the last step and submit your modification request for review and approval. Include a copy of the bar code cover sheet on any documentation you send. Please read The Short-Cut Guide to ProviderOne and review the steps outlined in the guide. This will ensure you are able to successfully bill in ProviderOne. For more information, including system training opportunities: http://hrsa.dshs.wa.gov/providerone/providers.htm Sign up for email broadcast messages regarding updates on ProviderOne at: http://listserv.wa.gov/archives/providerone_provider_readiness.html American LegalNet, Inc. www.FormsWorkFlow.com