Optima Health Enrollment Form

Provider Connection on OptimaHealth.com is a secure environment for physicians and their practice staff to access Health Plan transactions. Please complete the information for each potential OptimaHealth.com enrollee. Once submitted, the Practice Supervisor/Manager/MD will receive confirmation of the enrollment. A member of the Optima Health Support Staff will contact you regarding your login and password.

If you have questions, please contact the Optima Health Support HelpDesk at 757-552-7474 option 4 or toll free at 800-229-8822.

*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. I understand that with the implementation of the on-line health plan information, our practice will begin receiving documents, manuals, directories and bulletins from Optima Health online, instead of by mail and/or fax.
Paper remits will not be provided when the provider begins to receive payments and remits electronically by means of EFT (Electronic Fund Transfer)/ERA (Electronic Remittance Advice) of eRemits.
*Acceptance Agreement:
*Type of Request:
If Account Change please describe type of change:
*Is this a Practice or Billing Company? Check one.
*Do you or any physicians in your practice have admitting/consulting privileges at any Sentara facility?
*Do you refer patients to Sentara facilities for outpatient diagnostic, labs or emergency services?
If the answer to either of the previous two (2) questions is YES, do not complete this enrollment form. You will need to register for MDoffice. Please click on the link MDoffice Enrollment Form to enroll in MDoffice.
Part 1: User Login Information
*First Name:
*Middle Initial: (Use NMN for no middle initial)
*Last Name:
Suffix (Jr,Sr,etc)
Title: (MD,PA,RN,
*Date of Birth:
Pager Number:
Business Phone:
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: