Get Optum Provider Network Participation Request Form 2021-2025

This guide provides clear instructions to assist you in completing the Optum Provider Network Participation Request Form online. By following these steps, you can efficiently provide the necessary information to join the Optum network.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your online document editor.
2. Enter today’s date in the designated field to ensure your application is current.
3. Provide your provider legal name to identify your facility.
4. Include your NCPDP/NPI number for proper identification in the network.
5. Select your affiliate code: choose between Chain, PSAO, or Independent, as applicable.
6. If you selected PSAO, please enter the affiliate name for further association.
7. Indicate your pharmacy type by checking one or more of the options provided, such as Retail, Clinic, or Mail.
8. List all services offered by your pharmacy, including options like Compounding or Specialty Distribution.
9. Fill in the pharmacy address, including city, state, zip code, and any contact information.
10. Provide the contact name, email, phone number, and fax number for communication purposes.
11. Respond to the additional information questions, including termination date if affiliated with a PSAO, change of ownership, store open date, and federal Indian reservation status.
12. Indicate whether your pharmacy dispenses medications to Medicaid beneficiaries and provide the required Medicaid ID and related details if applicable.
13. Enter the name and title of the individual authorized to execute the agreement, along with their email for correspondence.
14. Review all the entered information for accuracy before finalizing your form.
15. Save your changes, then download, print, or share the completed form as needed.

Complete your Optum Provider Network Participation Request Form online today!