APS Portal Access Instructions The form is a writable PDF. Please type the information directly into the form. Part A: Type of Application Please check AT LEAST ONE CHECK BOX. Part B: User Contact Information Every individual provider attesting must complete all required information in part A. Please make sure that ALL information (including your email address) is correct before submitting. If incorrect/insufficient information is received, your request cannot be completed. All fields of Part A that pertained to the individual provider are required information. Part C: Facility/Business Type Please check AT LEAST ONE CHECK BOX for the Facility Business type that apply. If the Facility/Business Type is not in the list, please select other and specify the Facility/Business Type. Part D: User Role at Facility/Business Please check AT LEAST ONE CHECK BOX for the User Role that applies. If the User Role Type is not in the list, please select other and specify the User Role Type. Part E, F and G: Purpose, Restrictions, and Attestation Please read and review attestation policy. Part H: Signature After reviewing parts A thru D, please print the attestation, sign and date the form and send it to L.A. Care Health Plan/Provider Portal Oversight Unit as indicated below: Two options are available for submission of Attestation Forms: Email: [email protected] (Indicate subject as “HRA Access”) Fax: 213-438-5792 (Indicate “HRA Access” in fax cover sheet subject line) An APS Representative will complete your set up and return your login information within five (5) business days*. *NOTE: An L.A. Care Representative will contact the requestor if the attestation form is incomplete. Please keep in mind that any inaccuracy in the information submitted will delay the receipt of login information. If you do not access the APS system, once you received your log in information, your account will be disabled after 30 days of inactivity.
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