Provider Portal Web Application Submission Form

Provider Portal Web Application Submission Form

Review the instructions and prepare your required information before submitting your application.
Required Information:
W9 Required: Please prepare a copy of your W9 for file upload.
Contracted Providers Only: Only contracted providers may view or submit claims and authorizations.
Third-Party Billers: No access will be granted without prior medical group approval.

Important: Multiple Tax IDs
If your practice or individual NPI operates under more than one Tax ID, you must submit each additional Tax ID with your corresponding W9(s) at time of registration to: Portal@imperialhealthholdings.com. List all Tax IDs you are associated with. This allows us to properly link your accounts in the provider portal.

Failing to provide all Tax IDs may result in:
- Inability to view or verify patient eligibility
- Missing access to assigned members
- Claim submission issues
- Overall restricted portal functionality
Providing full and accurate Tax IDs ensures your account loads correctly and prevents service interruptions.

User Agreement
A. You will comply with all HIPAA regulations and safeguard all devices, systems, and software used to access the portal.
B. You will maintain appropriate security protections (e.g., virus scans, firewalls) and perform periodic assessments.
C. All staff or delegated associates accessing the portal will have signed confidentiality agreements and received appropriate HIPAA training
D. All information you submit to Imperial Health Holdings is accurate, reliable, and complete.
E. You will notify Imperial when a user’s access must be deactivated. A new application is required for replacement users.
F. Any uncured breach within 30 days of notice may result in immediate termination of portal access.
G. Imperial Health Holdings may deny or deactivate access at any time.
If you have read the above please select Yes*
Provider Type*

Contracted ProviderNon-Contracted ProviderIPA/MSO
Non-Contracted Provider Information

Complete this section if you are not a contracted provider.
Billing Contact Name*
Billing Email Address*
example@example.com
Billing Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Additional Information
IPA Information
IPA Name*
Tax ID*
If more than 10 tax IDs, please use the Bulk Portal Registration Form below.
Bulk Portal Registration Form
Bulk Registration Excel File Upload

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If your NPI is associated with any additional Tax IDs, please enter them below and send your W9(s) via email to: Portal@imperialhealthholdings.com.
Additional Tax ID(s)
W9 File Upload*

Cancelof
Provider Information
Provider First Name*
Provider Last Name*
Group / Organization*
Tax ID*
If more than 10 tax IDs, please use the Bulk Portal Registration Form below.
Bulk Portal Registration Form
Bulk Registration Excel File Upload

Cancelof
If your NPI is associated with any additional Tax IDs, please enter them below and send your W9(s) via email to: Portal@imperialhealthholdings.com.
Additional Tax ID(s)
National Provider Identifier (NPI)*
W9 File Upload*

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Location Information
Street Address*
Is the mailing address the same as the physical location address shown above? If it is different, please provide the mailing address.
Mailing Address (If Different)
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Staff User Information
First Name*
Last Name*
Title*
Email Address*
example@example.com
Phone Number (If Different)
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Provider Portal Web Application Submission Form

Non-Contracted Provider Information

IPA Information

Provider Information

Location Information

Staff User Information