Form 1 PRF and ARP-R Attestation and Application Screenshots.pp

Provider Relief Fund (PRF)

 

PRF and ARPA–R Attestation Portal

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To proceed further, please select Eligibility ‘Yes’.

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Please select Eligibility ‘Yes’ and continue

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Please enter Billing TIN and continue.

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Please enter last six digits of the account number, exact amount and continue

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Please Review the information and Accept

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Please attest to Payment Terms Attestation, enter information in all the required fields, agree to terms and conditions and select I Accept Payment

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Please attest to Payment Terms Attestation, enter information in all the required fields, agree to terms and conditions and select I Accept Payment

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Please attest to Payment Terms Attestation, enter information in all the required fields, agree to terms and conditions and select I Accept Payment

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Confirmation

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Please enter complete check number, exact amount and continue

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Please Review and Accept

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Please attest to Payment Terms Attestation, enter information in all the required fields, agree to terms and conditions and accept or reject payments

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Please attest to Payment Terms Attestation, enter information in all the required fields, agree to terms and conditions and accept or reject payments

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Please attest to Payment Terms Attestation, enter information in all the required fields, agree to terms and conditions and accept or reject payments

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Confirmation

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PRF Phase 4/ARPA–R Application Portal

 

Landing Page:

• •Contains general information about the program and how to request funds 

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• •Instructions to set up Optum ID  

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What you need tab has some additional information about the three main steps for this program

Once I log into the portal, I will walk through these three steps

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The resources and support tab has some reference material. The first link is an interactive guide with some helpful tips.

Once you have reviewed the program materials and created an Optum ID (if required), please select “Sign In” in the upper righthand corner to access the portal and begin with TIN submission process.

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Please Add your Organization TIN, Provider Name and TIN Type

Note: Please enter the Provider Organization Name exactly as it appears on your W-9

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Please attest to serve as the program administrator role for the tax ID.

Note: No other user will be able to access this tax ID if you attest as the program administrator.

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Please select your Organization Federal Tax Classification, Exempt Payee Code, and Exempt from FATCA reporting code and select Continue

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Please select your Organization Federal Tax Classification, Exempt Payee Code, and Exempt from FATCA reporting code and select Continue

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Please enter Organization TIN Address and/or Billing Company information and Continue

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Please enter Organization TIN Address and/or Billing Company information and Continue

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Please enter primary servicing location information for your organization TIN.

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Please select your registration type – either Group or Individual and provider information in all the required fields

All required fields are marked with an Asterix

Please enter subsidiary TIN and TIN Type.

If your organization doesn’t have any Subsidiary TINs, please re-enter your Organization TIN and select TIN Type.

If your organization has multiple Subsidiary TINs, please type or paste TINs, select TIN Type for each TIN.

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Please select your registration type – either Group or Individual and provider information in all the required fields

All required fields are marked with an Asterix

Please enter subsidiary TIN and TIN Type.

If your organization doesn’t have any Subsidiary TINs, please re-enter your Organization TIN and select TIN Type.

If your organization has multiple Subsidiary TINs, please type or paste TINs, select TIN Type for each TIN.

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Review the detail to make sure all information was inputted correctly. If there are any changes needed, select the back button in the upper left corner – otherwise select Submit TIN

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You will now be brought back to the Organization TIN Dashboard.

You will receive an email once your TIN validation is complete.

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Once TIN validation is complete and can proceed with Revenue and Tax Information step.

Select Get Started link under Revenue and Tax Information, proceed to the DocuSign form.

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You will receive an email with an Access Code to proceed to the Docusign form

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Enter information in all the required fields within the DocuSign form

You will notice certain data from the TIN validation step is automatically populated for you

Many of the fields have tooltips to help you through the application process.

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Enter information in all the required fields within the DocuSign form

Many of the fields have tooltips to help you through the application process.

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Once you have finished filling in all the required information, please submit

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You will be taken back to the Dashboard.

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Once you have received payment, the dashboard option to Attest to Payment and Terms will be activated.

In this last step, you will attest to accepting or rejecting funds. Payments will include “HHS.gov” in the ACH descriptor. If you do receive a check, you may notice “UnitedHealth Group / OptumRx” on the check; the funds, however, are from HHS. Please have the exact amount of the payment available to complete the attestation.

As a reminder, HHS will make publicly available the names of providers and amounts received as part of the relief fund.

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Please input the check number or last 6 digits of your account number along with the relief fund payment amount you received and continue

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Please accept to the funds and terms and conditions.

If you choose to accept and attest to the funds, no further l action is required!

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You will be taken back to the Organization TIN Dashboard

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Once you have received payment, the dashboard option to Attest to Payment and Terms will be activated.

In this last step, you will attest to accepting or rejecting funds. Payments will include “HHS.gov” in the ACH descriptor. If you do receive a check, you may notice “UnitedHealth Group / OptumRx” on the check; the funds, however, are from HHS. Please have the exact amount of the payment available to complete the attestation.

As a reminder, HHS will make publicly available the names of providers and amounts received as part of the relief fund.

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Please input the check number or last 6 digits of your account number along with the relief fund payment amount you received and continue

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Please accept to the funds and terms and conditions.

If you choose to accept and attest to the funds, no further l action is required!

If you choose to reject and return the funds, the portal will provide instructions to return your Check or Bank Deposit

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Rejected Payment Information – how to return funds

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Rejected Payment Information – how to return funds and Reject Payment

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You will be taken back to the Organization TIN Dashboard

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Discussion

 

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