Get Optum Provider Network Participation Request Form 2015-2025

This guide provides comprehensive instructions on how to complete the Optum Provider Network Participation Request Form online. By following the steps outlined here, users can ensure that their application is filled out accurately and submitted efficiently.

Follow the steps to complete the form online

1. Press the ‘Get Form’ button to access the Optum Provider Network Participation Request Form and open it for editing.
2. Begin by entering today's date in the designated field. This information helps track when the form is filled.
3. Provide the provider legal name in the appropriate section. This should reflect the official name under which your pharmacy operates.
4. Input your NCPDP number. This unique identification number is essential for pharmacy services.
5. Indicate your affiliate code by selecting one of the following options: Chain, PSAO, or Independent.
6. Enter your National Provider Identifier (NPI) number, which is vital for identification purposes.
7. Select your pharmacy type from the options provided: Retail, Clinic, Outpatient Hospital, Mail, Specialty, Long Term Care, Hospice, or Other. Specify if choosing 'Other'.
8. List the services offered by your pharmacy, checking all applicable boxes such as Compounding, DME, Mail, or Specialty.
9. Fill in the pharmacy address, including street address, city, state, zip code, and contact information such as name, email, phone, and fax.
10. In the additional information section, answer questions about provider agreements with OptumRx and Catamaran, if applicable. Include details of the agreement, effective dates, and legal entity.
11. Answer yes or no to whether your pharmacy dispenses medications to Medicare beneficiaries, if located on a Federal Indian Reservation, and whether it dispenses to Medicaid beneficiaries.
12. If applicable, fill in the Claim Information section, including BIN, Date of Service, and Prescription Number.
13. Finalize by signing where indicated, providing the name of the authorized individual, their title, and ensuring that the form is completed by the designated person.
14. Once all fields are filled, users can save changes, download, print, or share the completed form as needed.

Complete your Optum Provider Network Participation Request Form online today.