Medicaid and Medicare Auditing and Consulting | Myers ...



Indiana Long Term Care Rate Setting and Compliance ReviewsUser Account Information FormFacilityThe secure web portal is used to distribute information requests and correspondence, compliance review draft and final reports, and Medicaid rate notifications and cost profiles. In addition, the secure web portal may be used to submit information to Myers and Stauffer LC, such as requested rate setting and compliance review information, correspondence, and cost report submissions. In order to implement this process, please complete this form and email the completed form to: LTCDept@ or fax to 317-571-8481. If the Facility Information (Facility Name and Facility Medicaid Number) is not complete and accurate, the user account information will not be acceptedFacility Information (Required)Facility Name: MERGEFIELD "ProviderName" ?ProviderName?Facility Medicaid Number: MERGEFIELD "ProviderFacilityID" ?ProviderFacilityID?Primary Contact Information (maximum of 3) Note: If a contact from the home office needs access, they are considered one of the 3.Contact #1 Name:Contact #3 Name:Contact #1 Title:Contact #3 Title:Contact #1 Phone Number:Contact #3 Phone Number:Contact #1 Email Account:Contact #3 Email Account:Contact #1 IP Address:Contact #3 IP Address:Contact #2 Name:Contact #2 Title:Contact #2 Phone Number:Contact #2 Email Account:Contact #2 IP Address: MERGEFIELD "UserLastIPAddress" Cost Report Preparer Contact Information* (maximum of 2)Contact #1 Name:Contact #2 Name:Contact #1 Phone Number:Contact #2 Phone Number:Contact #1 Email Account:Contact #2 Email Account:Contact #1 IP Address:Contact #2 IP Address:*The cost report preparer access is optionalTo determine the computer IP address, from the computer you plan to use to access the web portal, connect to the internet and go to . Using the Google search box, type “what is my public ip address.” Based on your web browser, your ip address will either be returned or you will be prompted with several web pages you can select that will return your ip address. If you have any trouble determining your ip address, please call the Myers and Stauffer helpdesk at (800)877-6927.If you have any questions regarding this request or have changes to be made to your information, contact Chrissy Lahey-Hawkins at Myers and Stauffer 317-846-9521 or email LTCdept@. Please include “Web Portal” in your subject line. ................
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