To submit a request for access to the Optum Provider website, you must complete all required fields on the form below. Once your request is submitted, you will receive an approval or denial e-mail within 1-2 business days. If approved, you will receive a second e-mail from noreply_provisioning@optum.com to create a One Healthcare ID, which you will use to log into the site.
All fields marked with an asterisk (*) are required.
First Name*:
Last Name*:
Email*:
Professional Title: (e.g. RN, MD, CCM)
Position Title: (role in your organization)
Address 1*:
Address 2:
Address 3:
City*:
State*: Alabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)District of Columbia (DC)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinois (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky (KY)Louisiana (LA)Maine (ME)Maryland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)Montana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New Mexico (NM)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Puerto Rico (PR)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virgin Islands (VI)Virginia (VA)Washington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)
Zip*:
Phone Number*:
Extension:
Fax Number:
The following role applies to my interaction with OptumHealth Care Solutions - Complex Medical Conditions*:
Access Request Reason / Notes:
You will have to agree to the Disclaimer prior to using your login.