Follow the steps to complete your application with ease.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred document interface.
2. Begin with the organizational facility identifying information section. Fill in the legal name of your facility, any parent company name, and the DBA (doing business as) name if applicable. Ensure that the administrative address, phone number, and email address are correct.
3. Provide the tax identification number and national provider identifier (NPI) for both primary and secondary if applicable. This information is critical for accurate processing in the Optum system.
4. Identify the levels of care your facility wishes to contract. Be sure to select all applicable options, from inpatient and outpatient services to specialized programs.
5. List the practice locations related to the selected levels of care. Detail each location’s information including admission types, phone numbers, and number of beds.
6. Fill out the organizational provider contact information section, ensuring to select the primary contact roles accurately.
7. Accreditations must be listed along with issue and expiration dates, if applicable. If you lack accreditation, note that a site visit may be required.
8. In the licensure/certification section, list any licenses or certifications held by your organization and their respective issuing entities, also attaching relevant documentation as indicated.
9. Complete the Medicare/Medicaid information section with the necessary ID numbers and validation dates to ensure compliance.
10. Provide general and professional liability insurance details. Make sure to include current certificates and required coverage limits as specified.
11. Respond to the legal status question regarding any disciplinary measures. If applicable, provide an explanation.
12. Fill out the accessibility information to demonstrate compliance with access needs.
13. Sign and date the application, certifying the accuracy of the provided information and your authority to submit the application.
14. Finally, review the preparation checklist and ensure all required documents are attached before saving the application. You can then download, print, or share the completed form.

Complete your CA OptumHealth Facility Application online today to ensure your facility's participation in the Optum network.