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Provider Supplemental Information Request Form. This is a Washington form and can be use in Department Of Social And Health Services Statewide.
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Tags: Provider Supplemental Information Request, Washington Statewide, Department Of Social And Health Services
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
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