Optima Health Enrollment Form

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:

I Agree to the terms listed above.

*Type of Request:

- Select Request - New User Account Change Account Reactivation

If Account Change please describe type of change:

*Is this a Practice or Billing Company? Check one.

Practice Billing Company

*Do you or any physicians in your practice have admitting/consulting privileges at any Sentara facility?

Yes No

*Do you refer patients to Sentara facilities for outpatient diagnostic, labs or emergency services?

Yes No

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, LPN,etc)

*Date of Birth: (mm-dd-yyyy)

*SSN: (xxx-xx-xxxx)

Gender:

Female Male

Pager Number:

Business Phone:

*Email

Part 2: Practice or Billing Company Demographic Information

*Name of Practice or Billing Company:

*Address:

*City:

*State:

Virginia Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code:

*Telephone:

*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)

MD Resident PA/NP Clinical (Access to clinical/demographic data) Administrative/Billing (Access to demographic/billing data) Administrative/Billing and Clinical (Access to clinical & demographic/billing data) Contracted Billing Company Employee (Complete Part 4)

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?

Yes No

If Contract Billing Company, has a Business Associate Agreement between your company and the provider office(s) you represent been filed with Optima Health.

Yes No

Part 5: Practice Supervisor (i.e., Practice Manager or MD.)

*Supervisor Name:

*Email

Telephone: