Optima Health Provider Connection Registration Form

Provider Connection is a secure environment for physicians and practice staff to access Optima Health Plan transactions. Please complete the registration form below for each Provider Connection user; username and password information is confidential and should not be shared.

After the registration has been submitted and processed, the user will receive a secure email with a username and temporary password. Sign in to Provider Connection will be available immediately. Users will have instant access to member eligibility, benefits, and claim information; access to remits will be available the day after the email is received.

If you have any questions, please contact Optima Health Provider Services.

*An asterisk denotes required information

Acceptance Agreement
I acknowledge that the user below is an authorized representative of this practice/facility. I agree to notify Optima Health promptly of additions or deletions of users by requesting an “Account Change” on this form. I understand that with the implementation of on-line health plan information, our practice will receive information from Optima Health electronically, instead of by mail and/or fax.
*Acceptance Agreement:
*Type of Request:
If Account Change please describe type of change:
*Is this a Practice or Billing Company? Check one.
*This access is being requested for:
*Do you or any physicians in your practice have admitting/consulting privileges at any Sentara Healthcare facility?**
*Do you refer patients to Sentara Healthcare facilities for outpatient diagnostic, labs or emergency services?**
**If the answer to either of the previous two (2) questions is YES, please do not complete this enrollment form. You will need to register for MDoffice. MDoffice Enrollment Form
Part 1: User Information
*First Name:
*Middle Initial: (Use NMN for no middle initial)
*Last Name:
Suffix (Jr,Sr,etc)
Title: (MD,PA,RN,
Practice Manager,etc)
*Date of Birth:
Part 2: Practice or Billing Company Demographic Information
*Name of Practice or Billing Company:
*Zip Code:
*Tax ID Number:
Please include the vendor numbers for all practices for which you are requesting access.
Vendor Numbers:
Part 3: Role Information (Select one)
Part 4: Contract Billing Company Information
Contract Billing Company ONLY: This section applies only if you are a billing company contracted by the physician practice. List the name of all practice(s) for which you provide billing services.
If Contract Billing Company, do you require access to Patient Clinical Data?
If Contract Billing Company, has a Business Associate Agreement between your company and the provider office(s) you represent been filed with Optima Health.
Part 5: Practice Supervisor (i.e., Practice Manager or MD.)
*Supervisor Name: