Get Optum Individual Therapist Credentialing Form

This guide provides a step-by-step approach for accurately completing the Optum Individual Therapist Credentialing Form online. By following these instructions, you can ensure that all necessary details are submitted correctly for the credentialing process.

Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to access the Optum Individual Therapist Credentialing Form and open it in your preferred editor.
2. Begin by filling out the clinic information section. Provide details such as the STE number, APT number, UNIT number, group name, clinic address, phone number, email, fax number, city, state, zip code, and TIN.
3. Next, move to the therapist information section. For each therapist, enter their first name, middle initial, last name, former last name (if applicable), date of birth, social security number, individual Medicaid number, NPI, CAQH ID, phone number, email, and fax number.
4. Make sure to indicate the therapist's specialty. You can find options such as Occupational Therapist (OT), Physical Therapist (PT), and Speech-Language Pathologist (SLP) within the form.
5. If you are filling out the form for multiple therapists, repeat the information entry for up to four therapists per form, ensuring all details are complete.
6. After entering all necessary information, review the completed form thoroughly to verify that all data is accurate and fully completed.
7. Finally, save your changes, download the form, print it out for your records, or share it as required. Be sure to send the completed form to optumcred@optum.com or fax it to 877-309-9421 for processing.

Begin completing your Optum Individual Therapist Credentialing Form online today!