MDoffice Enrollment Form

MDoffice is a secure environment for Physician Offices containing applications for physicians and their practice staff to assist with patient care and improve business processes. Please complete the information for each potential MDoffice enrollee. Once submitted, the Practice Supervisor/Manager/MD will receive confirmation of the enrollment.

If you have questions, please contact the Physician Support HelpDesk at either (757)388-5300 or 1-866-209-0998 (toll free).

*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 Sentara Healthcare 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 Sentara on-line, 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:
Users requesting Optima Health Plan access for Claims and Referrals click on the following link for the Optima Health Enrollment Form.

Users requesting access to Patient Clinical information on behalf of physicians who meet either of the following qualifications should continue completing this form:
1) Have admitting or consulting privileges at Sentara hospitals
2) Refer patients to Sentara hospitals for outpatient diagnostic, labs or emergency services
Part 1: User Login Information
*First Name:
*Middle Initial: (Use NMN for no middle initial)
*Last Name:
Suffix (Jr,Sr,etc)
*Date of Birth:
(mm-dd-yyyy)
Title/License: (MD,PA,RN,
LPN,etc)
*SSN:
(xxx-xx-xxxx)
*Gender:
Pager Number:
Business Phone:
*Email
Part 2A: Practice or Billing Company Demographic Information
*Name of Practice or Billing Company:
*Address:
*City:
*State:
*Zip Code:
*Telephone:
(xxx-xxx-xxxx)
Tax ID Number:
Vendor Numbers:
Part 2B: Practice or Billing Company Demographic Information
Name of Practice or Billing Company:
Address:
City:
State:
Zip:
Telephone:
(xxx-xxx-xxxx)
Tax ID Number:
Vendor Numbers:
Part 3: Role Information (Select one)*

Part 4: Required Information (Yes or No)
Part 5: Practice Supervisor (I.e., Practice Manager or Physician.)
*Supervisor Name:
*Email
*Telephone:
(xxx-xxx-xxxx)