MDoffice Enrollment Form
MDoffice is a secure environment for
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
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.
I Agree to the terms listed above.
*Type of Request:
- Select Request -
If Account Change please describe type of change:
Users requesting Optima Health Plan access for
click on the following link for the
Optima Health Enrollment Form
Users requesting access to
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
*Middle Initial: (Use NMN for no middle initial)
*Date of Birth:
Part 2A: Practice or Billing Company Demographic Information
*Name of Practice or Billing Company:
Tax ID Number:
Part 2B: Practice or Billing Company Demographic Information
Name of Practice or Billing Company:
Tax ID Number:
Part 3: Role Information (Select one)*
Medical Student (1st or 2nd Year)
Medical Student (3rd or 4th Year)
EpicCare Link Administrator
Part 4: Required Information
(Yes or No)
User will be requesting patients to be scheduled for the Sentara Surgery Suite
User will be scheduling Radiology procedures to be done for patients at Sentara facilities
Practice has NOT completed an EpicCare Link conversion (check with your Practice Manager)
Part 5: Practice Supervisor
(I.e., Practice Manager or Physician.)