Medical, Hospital and Dental Enrollment Forms

<!DOCTYPE HTML> <html lang="en"> <head> <meta charset="UTF-8"/>  <script defer="defer" type="text/javascript" src="/.rum/@adobe/helix-rum-js@%5E2/dist/rum-standalone.js"></script> <script type="text/javascript" fetchpriority="high"> window.lpTag = window.lpTag || {}, 'undefined' == typeof window.lpTag._tagCount ? (window.lpTag = { wl: lpTag.wl || null, scp: lpTag.scp || null, site: '23120590' || '', section: lpTag.section || '', tagletSection: lpTag.tagletSection || null, autoStart: lpTag.autoStart !== !1, ovr: lpTag.ovr || {}, _v: '1.10.0', _tagCount: 1, protocol: 'https:', events: { bind: function (t, e, i) { lpTag.defer(function () { lpTag.events.bind(t, e, i) }, 0) }, trigger: function (t, e, i) { lpTag.defer(function () { lpTag.events.trigger(t, e, i) }, 1) } }, defer: function (t, e) { 0 === e ? (this._defB = this._defB || [], this._defB.push(t)) : 1 === e ? (this._defT = this._defT || [], this._defT.push(t)) : (this._defL = this._defL || [], this._defL.push(t)) }, load: function (t, e, i) { var n = this; setTimeout(function () { n._load(t, e, i) }, 0) }, _load: function (t, e, i) { var n = t; t || (n = this.protocol + '//' + (this.ovr && this.ovr.domain ? this.ovr.domain : 'lptag.liveperson.net') + '/tag/tag.js?site=' + this.site); var o = document.createElement('script'); o.setAttribute('charset', e ? e : 'UTF-8'), i && o.setAttribute('id', i), o.setAttribute('src', n), document.getElementsByTagName('head').item(0).appendChild(o) }, init: function () { this._timing = this._timing || {}, this._timing.start = (new Date).getTime(); var t = this; window.attachEvent ? window.attachEvent('onload', function () { t._domReady('domReady') }) : (window.addEventListener('DOMContentLoaded', function () { t._domReady('contReady') }, !1), window.addEventListener('load', function () { t._domReady('domReady') }, !1)), 'undefined' === typeof window._lptStop && this.load() }, start: function () { this.autoStart = !0 }, _domReady: function (t) { this.isDom || (this.isDom = !0, this.events.trigger('LPT', 'DOM_READY', { t: t })), this._timing[t] = (new Date).getTime() }, vars: lpTag.vars || [], dbs: lpTag.dbs || [], ctn: lpTag.ctn || [], sdes: lpTag.sdes || [], hooks: lpTag.hooks || [], identities: lpTag.identities || [], ev: lpTag.ev || [] }, lpTag.init()) : window.lpTag._tagCount += 1; </script>  <meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no"/> <meta name="twitter:card" content="summary_large_image"/> <meta property="og:type" content="website"/> <meta property="fb:app_id" content="287828061879318"/> <link rel="canonical" href="https://business.optum.com/en/support/enrollment-forms.html"/> <meta property="og:canonicalurl" content="https://business.optum.com/en/support/enrollment-forms.html"/> <meta property="og:title" content="Business support for Optum"/> <meta property="og:description" content="Get product help through our support portals, find resources such as enrollment forms and payer lists, sign up for the community, and more."/> <meta property="og:url" content="https://business.optum.com/en/support.html"/> <title>Medical, Hospital and Dental Enrollment Forms | Optum Business</title> <meta name="keywords" content="Support,Webpage text"/> <meta name="description" content="Find forms for medical claims, patient eligibility, ERA, and EFT payment information."/> <meta name="template" content="business-page-content"/> <meta name="robots" content="max-image-preview:large"/> <link rel="stylesheet" href="/etc.clientlibs/dmp/clientlibs/clientlib-base.lc-70267407c54bfd3d524dbb8e5bf56862-lc.min.css" type="text/css"> <script type="text/javascript"> (function() { window.ContextHub = window.ContextHub || {}; /* setting paths */ ContextHub.Paths = ContextHub.Paths || {}; ContextHub.Paths.CONTEXTHUB_PATH = "/etc/cloudsettings/default/contexthub"; ContextHub.Paths.RESOURCE_PATH = "\/content\/business\/en\/support\/enrollment\u002Dforms\/_jcr_content\/contexthub"; ContextHub.Paths.SEGMENTATION_PATH = "\/etc\/segmentation\/contexthub"; ContextHub.Paths.CQ_CONTEXT_PATH = ""; /* setting initial constants */ ContextHub.Constants = ContextHub.Constants || {}; ContextHub.Constants.ANONYMOUS_HOME = "/home/users/2/2wleTPcJflmUBvmxXMUY"; ContextHub.Constants.MODE = "no-ui"; }()); </script><script src="/etc/cloudsettings/default/contexthub.kernel.js" type="text/javascript"></script> <link rel="preconnect" href="https://fonts.googleapis.com"/> <link rel="preconnect" href="https://ajax.googleapis.com"/> <script src="//nav.optum.com/js/forms2/js/forms2.min.js"></script> <link rel="stylesheet" href="https://fonts.googleapis.com/css2?family=Material+Symbols+Rounded:opsz,wght,FILL,GRAD@48,400,0,0"/> <link rel="stylesheet" href="https://fonts.googleapis.com/css2?family=Material+Symbols+Outlined:opsz,wght,FILL,GRAD@48,400,0..1,0"/> <script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/3.6.0/jquery.min.js"></script> <script src="https://code.jquery.com/ui/1.13.2/jquery-ui.min.js" integrity="sha384-4D3G3GikQs6hLlLZGdz5wLFzuqE9v4yVGAcOH86y23JqBDPzj9viv0EqyfIa6YUL" crossorigin="anonymous"></script> <script src="/etc.clientlibs/optum3/clientlibs/clientlibs-contexthub.lc-d28e4f9976fdafdf8491b7a4408708a1-lc.min.js"></script> <input type="hidden" id="pageTitle" value="Medical, Hospital and Dental Enrollment Forms"/> <input type="hidden" id="archive"/> <input type="hidden" id="archiveTarget"/> <input type="hidden" id="articlePublishDate"/> <input type="hidden" id="articleEndDate"/> <input type="hidden" id="pageOwner" value="SmVuIEhlaWRlbnJlaWNoICYgQ2hhcmxlcw=="/> <input type="hidden" id="pageTemplate"/> <input type="hidden" id="pageName" value="enrollment-forms"/> <input type="hidden" id="pageLanguage" value="en"/> <input type="hidden" id="errorStr" value="false"/> <input type="hidden" id="isLaunch" value="yes"/> <input type="hidden" id="pageCampaign"/> <input type="hidden" id="pageChildCampaign"/> <input type="hidden" id="siteSection2" value="content"/> <input type="hidden" id="siteSection3" value="business"/> <input type="hidden" id="siteSection4" value="en"/> <input type="hidden" id="pageLastPublishDate" value="2024-11-14T06:51:19.483Z"/> <input type="hidden" id="pageLastPublishedBy" value="c2xpbmctZGlzdHJpYnV0aW9uLWltcG9ydGVy"/> <input type="hidden" id="pageLastModifiedDate" value="2024-11-26T17:27:35.860Z"/> <input type="hidden" id="pageLastModifiedBy" value="c2NvdHQuaG93YXJkQG9wdHVtLmNvbQ=="/> <input type="hidden" id="headLine" value="Enrollment forms"/> <input type="hidden" id="message" value="Optum has developed processes to allow payers and providers to electronically exchange sensitive information. Find forms for medical claims, patient eligibility, ERA, and EFT payment information."/> <input type="hidden" id="imageURL"/> <input type="hidden" id="pageType" value=""/> <input type="hidden" id="productName" value=""/> <input type="hidden" id="webProductName" value=""/> <script> var jsonData = {}; $("#productName").val(jsonData.productName); $("#webProductName").val(jsonData.webProductName); $("#pageType").val("Support" === "" ? undefined : "Support"); </script> <script> window.adobeDataLayer = window.adobeDataLayer || []; var pagelanguage = ""; if($('#pageLanguage').val() == "en"){ pagelanguage = "english"; } else if($('#pageLanguage').val() == "es") { pagelanguage = "spanish"; } var origin = window.location.origin; var hostName = window.location.hostname; var allowedHosts = ['business.optum.com']; var href = window.location.href; var businessSite=false; if(hostName.includes(allowedHosts)){ businessSite = true; } var targetWebsite = window.location.origin.split('.')[1]; var thumbnailUrl= origin + $('#imageURL').val(); if($('#imageURL').val() == ""){ thumbnailUrl =""; } var referrer = window.location.referrer; var portalName = ""; if(referrer != null && referrer != "") { if(referrer.indexOf("myuhc") > 0 || referrer.indexOf("laww") >0 || referrer.indexOf("optum") >0 || referrer.indexOf("uhg") >0 || referrer.indexOf("uhc") >0 || referrer.indexOf("everettclinic") > 0 || referrer.indexOf("polyclinic") > 0 || referrer.indexOf("care") > 0 || referrer.indexOf("bank") > 0) { portalName = referrer.replaceAll("http(s)?://|www\\.|/.*", ""); } } var viewName = $('#pageTitle').val(); if((window.location.pathname == "/")){ viewName = document.title; } if (window.location.hostname.includes('optumrx')) { adobeDataLayer.push({ event: 'viewStart', target: { targetBusinessUnit: 'optum', count: 'true', targetLanguage: $('#pageLanguage').val(), viewName: viewName, targetPageName: viewName, targetWebsite: targetWebsite } }); } if(href.indexOf("/forms/medicare-prescription-payment-plan") == -1 && href.indexOf("/forms/medicare-prescription-payment-plan/sample-payment-calculation") == -1) { adobeDataLayer.push( { event: 'page track', page: { experienceType: ( /Android|webOS|iPhone|iPad|iPod|BlackBerry|IEMobile|Opera Mini/i.test(navigator.userAgent) ) ? "mobile" : "desktop", is404: $('#errorStr').val(), lang: pagelanguage, name: $('#pageName').val(), group: $('#pageTemplate').val(), loginStatus: "not logged in", sitesection1: "public", sitesection2: $('#siteSection2').val() ? $('#siteSection2').val() : '', sitesection3: $('#siteSection3').val() ? $('#siteSection3').val() : '', sitesection4: $('#siteSection4').val() ? $('#siteSection4').val() : '', test: "", referringSite: portalName, // Only include customAttributes if all three have values customAttributes: (function() { var message = $('#message').val(); var image = $('#imageURL').val(); var headLine = $('#headLine').val(); if (businessSite == false && (message || image || headLine)) { return { message: message, headLine: headLine, thumbnailUrl: thumbnailUrl }; } else if(businessSite == true){ return { productName: $('#productName').val(), webProductName: $('#webProductName').val(), pageType: $('#pageType').val() }; } return ""; })(), attributes: { owner: $('#pageOwner').val(), campaign: $('#pageCampaign').val(), childCampaign: $('#pageChildCampaign').val(), lastModifiedBy: $('#pageLastModifiedBy').val(), lastModifiedDate: $('#pageLastModifiedDate').val(), lastPublishedBy: $('#pageLastPublishedBy').val(), lastPublishedDate: $('#pageLastPublishDate').val(), title: $('#pageTitle').val(), } }, user: { loginStatus: "not logged in", userType: "", groupId: "", carrierId: "", hsid: "", rallyId: "", patientId: "", payerGroup: "", memberId: "" } }); } else { adobeDataLayer.push( { event: 'page track', page: { experienceType: ( /Android|webOS|iPhone|iPad|iPod|BlackBerry|IEMobile|Opera Mini/i.test(navigator.userAgent) ) ? "mobile" : "desktop", is404: $('#errorStr').val(), lang: pagelanguage, name: $('#pageName').val(), group: $('#pageTemplate').val(), loginStatus: "not logged in", sitesection1: "public", sitesection2: $('#siteSection2').val() ? $('#siteSection2').val() : '', sitesection3: $('#siteSection3').val() ? $('#siteSection3').val() : '', sitesection4: $('#siteSection4').val() ? $('#siteSection4').val() : '', test: "", referringSite: portalName, // Only include customAttributes if all three have values customAttributes: (function() { var message = $('#message').val(); var image = $('#imageURL').val(); var headLine = $('#headLine').val(); if (businessSite == false && (message || image || headLine)) { return { message: message, headLine: headLine, thumbnailUrl: thumbnailUrl }; } return ""; })() }, user: { loginStatus: "not logged in", userType: "", groupId: "", carrierId: "", hsid: "", rallyId: "", patientId: "", payerGroup: "", memberId: "" } }); } </script>  <script th:inline="javascript"> /*console.log("test-o5"); $.ajax({ url: "/bin/optum3/adobeTargetConfiguration", type: 'GET', //beforeSend: function(xhr){ xhr.setRequestHeader("CSRF-Token", token);}, dataType: "json", success: function (json) { //console.log(json); window.targetGlobalSettings = { overrideMboxEdgeServer: true, serverState: json } }, error: function(){ console.log("error"); } });*/ </script> <script> var targetPrehidingSnippetVariable = ".o5-homepage-hero__container"; if(window.location.pathname.indexOf("/financial-services.html") !== -1){ targetPrehidingSnippetVariable = ".o5-homepage-hero__textblock-container"; } if(window.location.pathname.indexOf("/pharmacy-services/medication-delivery.html") !== -1){ targetPrehidingSnippetVariable = ".o5-detail-hero-banner__main-heading_1"; } //prehiding snippet for Adobe Target with asynchronous tags deployment ;(function(win, doc, style, timeout) { var STYLE_ID = 'at-body-style'; function getParent() { return doc.getElementsByTagName('head')[0]; } function addStyle(parent, id, def) { if (!parent) { return; } var style = doc.createElement('style'); style.id = id; style.innerHTML = def; parent.appendChild(style); } function removeStyle(parent, id) { if (!parent) { return; } var style = doc.getElementById(id); if (!style) { return; } parent.removeChild(style); } addStyle(getParent(), STYLE_ID, style); setTimeout(function() { removeStyle(getParent(), STYLE_ID); }, timeout); }(window, document, targetPrehidingSnippetVariable+" {opacity: 0 !important}", 2500)); </script> <script> window.addEventListener("message", (evt) => { if (evt && evt.data && evt.data.event && (evt.data.event == 'search filter' ||evt.data.event == 'standard search')) { console.log(evt.data); window.adobeDataLayer.push(evt.data); } }); </script> <script src="//assets.adobedtm.com/512027f42d3c/d52f6c362542/launch-e8eea2d81161.min.js" async></script> <script type="application/ld+json"> { "@context": "http://schema.org", "@type": "WebSite", "url": "https://www.optum.com", "potentialAction": { "@type": "SearchAction", "target": "https://www.optum.com/search-results.html?q={search_term_string}", "query-input": "required name=search_term_string" } } </script> <script type="text/javascript"> if ( !window.CQ_Analytics ) { window.CQ_Analytics = {}; } if ( !CQ_Analytics.TestTarget ) { CQ_Analytics.TestTarget = {}; } CQ_Analytics.TestTarget.clientCode = 'unitedhealthgroup'; CQ_Analytics.TestTarget.currentPagePath = '\/content\/business\/en\/support\/enrollment\u002Dforms'; </script> <script src="/etc.clientlibs/cq/testandtarget/clientlibs/testandtarget/parameters.lc-775c9eb7ff4c48025fbe3d707bcf5f55-lc.min.js"></script> <script src="/etc.clientlibs/clientlibs/granite/jquery.lc-f9e8e8c279baf6a1a278042afe4f395a-lc.min.js"></script> <script src="/etc.clientlibs/cq/personalization/clientlib/personalization/integrations/commons.lc-3d73584ddfdcb853a3a5d76cd1da5be0-lc.min.js"></script> <script src="/etc.clientlibs/cq/testandtarget/clientlibs/testandtarget/atjs-integration.lc-72059b16059e0b405cbb8c1d6eb7257d-lc.min.js"></script> <script src="/etc.clientlibs/dmp/clientlibs/clientlib-dependencies.lc-24e7ddfc27c2923de342a14378c7ac4c-lc.min.js"></script> <link rel="stylesheet" href="/etc.clientlibs/dmp/clientlibs/clientlib-dependencies.lc-d41d8cd98f00b204e9800998ecf8427e-lc.min.css" type="text/css"> <link rel="stylesheet" href="/etc.clientlibs/dmp/clientlibs/clientlib-react.lc-d41d8cd98f00b204e9800998ecf8427e-lc.min.css" type="text/css"> <link rel="stylesheet" href="/etc.clientlibs/dmp/clientlibs/clientlib-site.lc-0c78275d865b84d384940be202786e1d-lc.min.css" type="text/css"> <script async src="/etc.clientlibs/core/wcm/components/commons/datalayer/v2/clientlibs/core.wcm.components.commons.datalayer.v2.lc-1e0136bad0acfb78be509234578e44f9-lc.min.js"></script> <script async src="/etc.clientlibs/core/wcm/components/commons/datalayer/acdl/core.wcm.components.commons.datalayer.acdl.lc-bf921af342fd2c40139671dbf0920a1f-lc.min.js"></script> </head> <body class="page basicpage" id="page-867265861e" data-cmp-data-layer-enabled> <a href="#main-content" class="skip-to-main assistText">Skip to main content</a> <script> window.adobeDataLayer = window.adobeDataLayer || []; adobeDataLayer.push({ page: JSON.parse("{\x22page\u002D867265861e\x22:{\x22@type\x22:\x22dmp\/components\/page\x22,\x22repo:modifyDate\x22:\x222024\u002D11\u002D26T17:27:35Z\x22,\x22dc:title\x22:\x22Medical, Hospital and Dental Enrollment Forms | Optum Business\x22,\x22dc:description\x22:\x22Find forms for medical claims, patient eligibility, ERA, and EFT payment information.\x22,\x22xdm:template\x22:\x22\/conf\/dmp\/settings\/wcm\/templates\/business\u002Dpage\u002Dcontent\x22,\x22xdm:language\x22:\x22en\x22,\x22xdm:tags\x22:[\x22Support\x22,\x22Webpage text\x22],\x22repo:path\x22:\x22\/content\/business\/en\/support\/enrollment\u002Dforms.html\x22}}"), event:'cmp:show', eventInfo: { path: 'page.page\u002D867265861e' } }); </script> <div class="root container responsivegrid"> <div id="container-df0270f590" class="cmp-container"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="o5-header-container aem-GridColumn aem-GridColumn--default--12"> <header class="o5-header"> <div class="o5-header__main brand-white">  <div> <div class="o5-dynamic-alerts" data-optum-cmp="o5-dynamic-alerts" qa_handles="O5-dynamic-alerts"> </div></div> <div class="o5-header__toggle"> <div class="o5-header-bar" data-optum-cmp="o5-header-bar" data-qahandle="o5-header-bar"> <div class="o5-header-bar__wrapper dmp-container"> <nav class="o5-site-toggle" aria-label="Optum Sites" data-qahandle="o5-site-toggle"> <ul class="o5-site-toggle__links" data-qahandle="o5-site-toggle__links"> <li class="o5-site-toggle__item o5-site-toggle__personal" data-qahandle="o5-site-toggle__item"> <a href="https://www.optum.com/en/" class="o5-site-toggle__link" data-qahandle="o5-site-toggle__link" data-mobile-label="Visit Optum">Personal</a> </li> <li class="o5-site-toggle__item o5-site-toggle__business" data-qahandle="o5-site-toggle__item"> <a href="https://business.optum.com/en/" class="o5-site-toggle__link" data-qahandle="o5-site-toggle__link" data-mobile-label="Optum for Business">Business</a> </li> </ul> </nav> </div> </div> </div> <div class="o5-header__wrapper-container"> <div class="o5-header__wrapper dmp-container"> <div class="o5-header__left col-sm-12 col-md-12 col-lg-6 col-xl-3"> <div class="o5-header__logo"> <div data-optum-cmp="o5-logo"> <div id="faviconLink" data-favicon="/content/dam/optum5/skins/icons/favicon.ico"> </div> <div class="show-in-edit-mode faux-edit-bar">Site Logo</div> <a class="o5-logo__link" href="/en.html"> <img class="o5-logo__img o5-logo__img--137" src="/content/dam/optum4/images/logos/optum-logo-ora-rgb1.svg" alt="Optum for Business logo"/> <span class="o5-logo__text">for Business</span> </a> </div></div> </div> <div class="o5-header__right col-sm-6 col-lg-6 col-xl-9"> <div class="o5-global-ues-search"> <div class="dmp-container o5-ues-search__container"> <span class="o5-ues-search__icon"> <svg class="ues-MuiBox-root o5-ues-search__svg" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 48 48" focusable="false" aria-hidden="true"> <path class="ues-MuiBox-root ues-optumdotcom-search-0" d="M39.8 41.95 26.65 28.8q-1.5 1.3-3.5 2.025-2 .725-4.25.725-5.4 0-9.15-3.75T6 18.75q0-5.3 3.75-9.05 3.75-3.75 9.1-3.75 5.3 0 9.025 3.75 3.725 3.75 3.725 9.05 0 2.15-.7 4.15-.7 2-2.1 3.75L42 39.75Zm-20.95-13.4q4.05 0 6.9-2.875Q28.6 22.8 28.6 18.75t-2.85-6.925Q22.9 8.95 18.85 8.95q-4.1 0-6.975 2.875T9 18.75q0 4.05 2.875 6.925t6.975 2.875Z"></path></svg> </span> Search </div> <div id="ues-search-component" class="o5-ues-search" data-component="ues-search" data-prop-model="{"sitecol":null,"searchEnable":false,"enableUES":true,"experienceKey":"none","uniqueId":null,"redirectUrl":null,"redirectUrlSERP":"/content/business/en/search-results","placeholderText":null,"appName":"optumbusiness","promptHeader":null,"cancelInheritanceForHelpfulcommon":"false","helpfulLinks":[],"commonSearches":[]}"></div> </div> <div class="o5-header__hamburger"> <button class="o5-header__menu-btn o5-header__menu-btn--open closed" aria-label="menu" aria-expanded="false"> <span class="o5-header__menu-icon"> <span></span> <span></span> <span></span> </span> </button> </div> <div class="o5-header__popout--overlay o5-header__right col-sm-6 col-lg-6 col-xl-9"> <div class="o5-header__popout" id="o5-header__popout"> <div class="o5-header__hamburger--mobile"> <button class="o5-header__menu-btn o5-header__menu-btn--close closed" aria-label="menu" aria-expanded="false"> <span class="o5-header__menu-icon"> <span></span> <span></span> <span></span> </span> </button> </div> <div class="o5-global-search"> <div class="o5-header-mobile-icon"></div> </div> <div class="o5-header__utility-desktop"> <nav aria-label="Utility" class="o5-utility" qa_handles="o5-utility-nav" data-optum-cmp="o5-utility-nav"> <ul class="o5-utility__list" qa_handles="o5-utility__list" data-prop-model="/content/business/en/support/enrollment-forms/jcr:content/root/o5_header_container/o5-utility-nav.model.json"> <li class="o5-utility__item"> <a class="o5-utility__link o5-header-mobile-icon" href="/en/sign-in.html"> Sign in </a> </li> <li class="o5-utility__item"> <button class="o5-utility__btn" aria-expanded="false" id="Support-69584" aria-haspopup="true" aria-controls="o5-utility__sublist--1761206693"> <span class="o5-utility__txt o5-header-mobile-icon"> Support </span> <span class="material-symbols-rounded" aria-hidden="true"> expand_more </span> </button> <div class="o5-utility__sub o5-utility__sub--hidden"> <ul aria-labelledby="Support-69584" class="o5-utility__sublist" id="o5-utility__sublist--1761206693"> <li> <a href="/en/support/portals.html" class="o5-utility__sublink"> <span class="o5-utility__subtext">Product support portals</span> </a> </li> <li> <a href="/en/support/enrollment-forms.html" class="o5-utility__sublink"> <span class="o5-utility__subtext">Enrollment forms</span> </a> </li> <li> <a href="/en/support/payer-lists.html" class="o5-utility__sublink"> <span class="o5-utility__subtext">Payer lists</span> </a> </li> <li> <a href="/en/support.html" class="o5-utility__sublink"> <span class="o5-utility__subtext">All support</span> </a> </li> </ul> </div> </li> <li class="o5-utility__item"> <div class="o5-link-button" data-optum-cmp="o5-link-button"> <div class="o5-link-button--button"> <button class="dmp-btn dmp-btn--md dmp-btn--1 o5-link-button--button-action-form" data-qahandle="o5-link-button--button-action-form"> Get in touch </button> <dialog id="modal-" class="o5-link-button--dialog" data-qahandle="o5-link-button--dialog"> <div class="o5-link-button--dialog-close"> <button class="o5-link-button--dialog-close-btn" type="button" aria-label="Close Dialog" data-qahandle="o5-link-button--dialog-close-btn"> <svg xmlns="http://www.w3.org/2000/svg" width="30" height="30" viewBox="0 0 30 30" fill="none"> <path d="M22.875 7.125C22.375 6.625 21.625 6.625 21.125 7.125L15 13.25L8.875 7.125C8.375 6.625 7.625 6.625 7.125 7.125C6.625 7.625 6.625 8.375 7.125 8.875L13.25 15L7.125 21.125C6.625 21.625 6.625 22.375 7.125 22.875C7.625 23.375 8.375 23.375 8.875 22.875L15 16.75L21.125 22.875C21.625 23.375 22.375 23.375 22.875 22.875C23.375 22.375 23.375 21.625 22.875 21.125L16.75 15L22.875 8.875C23.375 8.375 23.375 7.625 22.875 7.125Z" fill="#4B4D4F"/> </svg> </button> </div> <div class="o5-link-button--dialog-content"> <div class="popup-marketo-form o5-marketo-form"> <div class="o5-marketo-form-container"> <div class="o5-marketo-form" data-optum-cmp="o5-marketo-form"> <div class="o5-marketo-form__headline">Get in touch with our sales team today</div> <div class="o5-marketo-form__body-copy"><p>Fill out this form and we’ll get back to you shortly.</p> </div> <form data-mkto-form="1468" data-munchkin-id="243-DKH-914" data-gated-form="true"></form> <div class="o5-marketo-form__footer-copy"><p>Already a customer? Find your <a href="/en/support.html">support portal</a>.</p> </div> </div> <div class="o5-marketo-form__success" data-thank-you-page-title="Thank you for reaching out to Optum" data-thank-you-page-content="<p>You will be contacted shortly by a member of the Optum sales team.<strong></strong></p> " data-download-cta-label="Download" data-link-source="page" data-component-name="o5-marketo-form" data-resource-path-hashcode="-1505436494" role="status" aria-live="polite"> </div> </div> </div> </div> </dialog> </div> </div> </li> </ul> </nav> </div> </div> </div> </div> </div> </div> <div class="o5-progressive-reveal-nav-zindex"> <div class="o5-progressive-reveal-nav-mobile--overlay"></div> <nav aria-label="Main" class="o5-nav o5-progressive-reveal-nav-header" data-optum-cmp="o5-progressive-nav" qa_handles="o5-progressive-nav"> <div class="o5-progressive-reveal-nav-mobile" data-qahandle="o5-progressive-reveal-mega-nav-mobile-comp" data-component="O5RevealMobileMegaNav" data-prop-model="/content/business/en/jcr:content/root/o5_header_container/o5-progressive-nav.model.json"> </div> <div class="dmp-container o5-nav__container o5-progressive-reveal-nav-desktop" id="o5-reveal-mega-nav__leftContent"> <ul class="o5-reveal-mega-nav-wrapper"> <li class="o5-nav__item"> <div class="o5-progressive-reveal-mega-nav" data-qahandle="o5-progressive-reveal-mega-nav" data-component="O5RevealMegaNav" data-prop-buttonId="What-we-do-96337" data-prop-mainMenuLabel="What we do" data-prop-model="/content/business/en/jcr:content/root/o5_header_container/o5-progressive-nav/heroicon-0"> </div> </li> <li class="o5-nav__item"> <div class="o5-progressive-reveal-mega-nav" data-qahandle="o5-progressive-reveal-mega-nav" data-component="O5RevealMegaNav" data-prop-buttonId="Who-we-help-96571" data-prop-mainMenuLabel="Who we help" data-prop-model="/content/business/en/jcr:content/root/o5_header_container/o5-progressive-nav/heroicon-1"> </div> </li> <li class="o5-nav__item"> <div class="o5-progressive-reveal-mega-nav" data-qahandle="o5-progressive-reveal-mega-nav" data-component="O5RevealMegaNav" data-prop-buttonId="Healthcare-insights-22486" data-prop-mainMenuLabel="Healthcare insights" data-prop-model="/content/business/en/jcr:content/root/o5_header_container/o5-progressive-nav/heroicon-2"> </div> </li> </ul> </div> </nav> </div>  <div class="o5-l2-nav"> <div data-optum-cmp="o5-l2-nav" qa_handles="o5-l2-nav"> <div class="o5-l2-nav__container-bg"> <div class="dmp-container "> <div class="o5-l2-nav__container-content"> <nav class="o5-l2-nav o5-l2-web-nav"> <ul class="o5-l2-nav__wrapper" style="margin-bottom:0px"> </ul> </nav> <div class="o5-l2-nav__mobile"> <nav aria-label="Main" class="o5-l2-nav__mobile-nav"> <ul class="o5-l2-nav__mobile-wrapper"> <li class="o5-l2-nav__mobile-title dmp-type__body-3-bold"> <button class="o5-l2-nav__btn dmp-type__body-3-bold mb-title-dd" aria-expanded="false"> <span class="material-symbols-rounded" aria-hidden="true"> expand_more </span> </button> <div class="o5-l2-mb-title-dd o5-l2-nav__sub--hidden"> <ul style="padding-left:0"> </ul> </div> </li> </ul> </nav> </div> </div> </div> </div> </div> </div> <div> <div class="o5-l2-nav-standalone" data-optum-cmp="o5-l2-nav-standalone" qa_handles="o5-l2-nav-standalone"> <div class="o5-l2-nav-standalone__container-bg"> <div class="dmp-container "> <div class="o5-l2-nav-standalone__container-content"> <nav class="o5-l2-nav-standalone o5-l2-web-nav"> <ul class="o5-l2-nav-standalone__wrapper" style="margin-bottom:0px"> </ul> </nav> <div class="o5-l2-nav-standalone__mobile"> <nav aria-label="Main" class="o5-l2-nav-standalone__mobile-nav"> <ul class="o5-l2-nav-standalone__mobile-wrapper"> <li class="o5-l2-nav-standalone__mobile-title dmp-type__body-3-bold"> <button class="o5-l2-nav-standalone__btn dmp-type__body-3-bold mb-title-dd" aria-expanded="false"> <span class="material-symbols-rounded" aria-hidden="true"> expand_more </span> </button> <div class="o5-l2-mb-title-dd o5-l2-nav-standalone__sub--hidden"> <ul style="padding-left:0"> </ul> </div> </li> </ul> </nav> </div> </div> </div> </div> </div></div> <div class="breadcrumb__wrapper"> <div class="breadcrumb__bg" data-optum-cmp="breadcrumb" qa_handles="breadcrumb"> <div class="dmp-container"> <nav class="breadcrumb_comp dmp-type__small-1" aria-label="Breadcrumb"> <ul data-qahandle="breadcrumbs" class="unstyled breadcrumb-nav horizontal-list hidden" data-attr="/content/business"> <li class="breadcrumb__item js--ces-home" qa_handles="o5-breadcrumb__item"> <svg xmlns="http://www.w3.org/2000/svg" height="18" viewBox="0 -960 960 960" width="18" fill="#4b4d4f" class="breadcrumb__arrow-mobile" aria-hidden="true"> <path d="M530-270 350-450q-7-7-10-14.5t-3-15.5q0-8 3-15.5t10-14.5l180-180q13-13 30-13t30 13q13 13 13 30t-13 30L440-480l150 150q13 13 13 30t-13 30q-13 13-30 13t-30-13Z"/> </svg> <a class="breadcrumb__home dmp-type__body-3-bold" href="/en.html">Home</a> </li> <li class="breadcrumb__item animated hidden" qa_handles="o5-breadcrumb__item"> <svg xmlns="http://www.w3.org/2000/svg" height="18" viewBox="0 -960 960 960" width="18" fill="#4b4d4f" class="breadcrumb__arrow" qa_handles="o5-breadcrumb__arrow" aria-hidden="true"> <path d="M348-268q-11-11-11-28t11-28l156-156-156-156q-11-11-11-28t11-28q11-11 28-11t28 11l184 184q6 6 8.5 13t2.5 15q0 8-2.5 15t-8.5 13L404-268q-11 11-28 11t-28-11Z"/> </svg> <svg xmlns="http://www.w3.org/2000/svg" height="18" viewBox="0 -960 960 960" width="18" fill="#4b4d4f" class="breadcrumb__arrow-mobile" aria-hidden="true"> <path d="M530-270 350-450q-7-7-10-14.5t-3-15.5q0-8 3-15.5t10-14.5l180-180q13-13 30-13t30 13q13 13 13 30t-13 30L440-480l150 150q13 13 13 30t-13 30q-13 13-30 13t-30-13Z"/> </svg> <a class="breadcrumb__link dmp-type__body-3-bold" href="/">Section </a> </li> </ul> </nav> </div> </div> </header></div> <main class="container responsivegrid aem-GridColumn aem-GridColumn--default--12"> <div id="main-content" class="cmp-container"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="container responsivegrid aem-GridColumn aem-GridColumn--default--12"> <div id="container-41ba3ecc73" class="cmp-container"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="o5-detail-hero-banner aem-GridColumn aem-GridColumn--default--12"> <div id="o5-detail-hero-banner--154331653" class="cmp-o5-detail-hero-banner" data-optum-cmp="o5-detail-hero-banner" qa_handles="O5-detail-hero-banner"> <div class="o5-detail-hero-banner__container-generic o5-detail-hero-banner__brand-white dmp-container-fluid analytics_75handle"> <div class="dmp-container"> <div class="dmp-row o5-detail-hero-banner__rowClass"> <div class="dmp-col o5-detail-hero-banner__textAlignContainer"> <div class="o5-detail-hero-banner__genericSecWidth o5-detail-hero-banner__genericleftSecWidth"> <div class="o5-detail-hero-banner__content-generic-leftAlign"> <div class="o5-detail-hero-banner__header--genericleft"> <h1 id="heading--154331653" class="o5-detail-hero-banner__main-heading_1 dmp-type__display-2">Enrollment forms</h1> <div id="o5-detail-hero-banner_text--154331653" class="o5-detail-hero-banner__bodyCopy-generic dmp-type__body-1"><p><span class="o5-text__body-1">Optum has developed processes to allow payers and providers to electronically exchange sensitive information. Find forms for medical claims, patient eligibility, ERA, and EFT payment information.</span></p> </div> </div> <div class="o5-detail-hero-banner__button"> </div> </div> </div> </div> </div> </div> </div> </div> </div> <div class="o5-full-column dmp-margin__top-0 dmp-margin__bottom-80 aem-GridColumn aem-GridColumn--default--12"> <div id="o5-full-column-2099888066" class="dmp-bg__"> <div class="dmp-container"> <div class="dmp-row"> <div class="dmp-col-12 column-control-full"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="o5-text dmp-margin__bottom-32 aem-GridColumn aem-GridColumn--default--12"> <div promo-lpos="" promo-name="" data-optum-cmp="o5-text" qa_handles="O5-text-Component__text"> <div class="text-component text-inner"><p><span class="o5-text__body-2">If you don't see the form you’re looking for, please refer to the <a href="https://www.optumproportal.com/home">Optum Pro Portal</a>.</span></p> </div> </div> </div> <div class="o5-accordion dmp-margin__top-0 dmp-margin__bottom-0 aem-GridColumn aem-GridColumn--default--12"> <section id="o5-accordion-1196210048" class="o5-accordion__container dmp-container" qa_handles="o5-accordion" data-uid="1196210048" data-optum-cmp="o5-accordion"> <div class="o5-accordion__basic" qa_handles="o5-accordion__basic"> <input class="basictoggle" type="hidden" value="false"/> <div class="o5-accordion__section o5-accordion__faqsection jso5AccordionSection" qa_handles="o5-basic__section"> <h3 class="o5-accordion__head"> <button class="o5-accordion__button js-o5-accordion-btn" type="button" aria-expanded="false" tabindex="0"> <i class="o5-accordion__icon" aria-hidden="true"> <?xml version="1.0" encoding="UTF-8" ?> <svg class="careticon" xmlns="http://www.w3.org/2000/svg" width="36" height="36" viewBox="0 0 36 36" fill="none"> <path d="M13.95 10.05C13.35 10.65 13.35 11.55 13.95 12.15L19.8 18L13.95 23.85C13.35 24.45 13.35 25.35 13.95 25.95C14.55 26.55 15.45 26.55 16.05 25.95L22.95 19.05C23.55 18.45 23.55 17.55 22.95 16.95L16.05 10.05C15.45 9.44998 14.55 9.44998 13.95 10.05Z" fill="#0C55B8"/> </svg> </i> <span class="o5-accordion__basic-question dmp-type__heading-6 jso5AccordionQuestion" qa_handles="o5-accordion__basic"> Medical and hospital </span> </button> </h3> <div class="o5-accordion__basic-answer dmp-type__body-2 is--hidden jso5AccordionAnswer" role="region" qa_handles="o5-accordion__basic-answer"> <p><span class="o5-text__body-1"><strong>EFT Enrollment Forms</strong> (currently unavailable, coming soon)<br /> ePayment/EFT allows providers to receive payments electronically from payers that have contracted with Change Healthcare to perform this service.</span></p> <p><span class="o5-text__body-1"><strong>Real-time enrollment forms</strong></span><strong><br /> </strong><span class="o5-text__body-1">Real-time functions provide the ability to verify eligibility, check claims status, locate providers, review requests and responses and make claim-related financial inquiries. </span></p> <p><span class="o5-text__body-1">Each provider must be set up in the system to access real-time functions.</span></p> <ol><li><span class="o5-text__body-1">New customers: Please contact the sales team regarding real-time products.</span></li><li><span class="o5-text__body-1">Current customers: Please contact your vendor for assistance.</span></li></ol> <p><span class="o5-text__body-1"><strong>Commonly used real-time enrollment forms</strong></span></p> <ul><li><span class="o5-text__body-1"><a href="/content/dam/noindex-resources/business/pdfs/forms/Real-Time-MID-TID-TPG-1.pdf">CHC MID/TID/TPG Creation Form</a> – Initial request for a MID/TID or TPG</span></li><li><span class="o5-text__body-1"><a href="/content/dam/noindex-resources/business/pdfs/forms/Real-Time-Payer-Add-1.pdf">Real-time NPI Payer Add – Existing Clients – Add additional NPIs</a></span></li></ul> <p><span class="o5-text__body-1"><strong>Full list of enrollment forms<br /> </strong><a href="/content/dam/noindex-resources/business/pdfs/forms/Blue%20Cross%20Delaware.pdf">Blue Cross & Blue Shield of Delaware</a> <br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/94267ELIG.pdf">HealthPartners MN</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/SB980ELIG.pdf">Triple-S Salud</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/MAPLFELIG.pdf">Mapfre</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/L0170ELIG.pdf">Medical Card System (MCS)</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/L0210ELIG.pdf">MMM Healthcare</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/RP081ELIG.pdf">Preferred Medicare Choice (Reform)</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/973MAELIG1.pdf">Triple-S Advantage</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/66065ELIG.pdf">MMM Healthcare (Reform)</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/LVTCAID-OKC.pdf">Vermont Medicaid VT</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/CAELIG.pdf">California Medi-Cal</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/MTNSTElig.pdf">Mountain State Blue Cross of West Virginia</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/BCPACELIG.pdf">Highmark Blue Cross & Blue Shield of Pennsylvania</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/ADMPRELIG.pdf">Association de Maestros Puerto Rico</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/RP084ELIG.pdf">First Medical Health Plan (IMC)</a> <br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/Medicare.pdf">Medicare Medex</a><br /> <a href="/content/dam/noindex-resources/business/pdfs/forms/PREMDELIG.pdf">Preferred Medicare Choice</a><br /> </span></p> </div> </div> <div class="o5-accordion__section o5-accordion__faqsection jso5AccordionSection" qa_handles="o5-basic__section"> <h3 class="o5-accordion__head"> <button class="o5-accordion__button js-o5-accordion-btn" type="button" aria-expanded="false" tabindex="0"> <i class="o5-accordion__icon" aria-hidden="true"> <?xml version="1.0" encoding="UTF-8" ?> <svg class="careticon" xmlns="http://www.w3.org/2000/svg" width="36" height="36" viewBox="0 0 36 36" fill="none"> <path d="M13.95 10.05C13.35 10.65 13.35 11.55 13.95 12.15L19.8 18L13.95 23.85C13.35 24.45 13.35 25.35 13.95 25.95C14.55 26.55 15.45 26.55 16.05 25.95L22.95 19.05C23.55 18.45 23.55 17.55 22.95 16.95L16.05 10.05C15.45 9.44998 14.55 9.44998 13.95 10.05Z" fill="#0C55B8"/> </svg> </i> <span class="o5-accordion__basic-question dmp-type__heading-6 jso5AccordionQuestion" qa_handles="o5-accordion__basic"> Dental </span> </button> </h3> <div class="o5-accordion__basic-answer dmp-type__body-2 is--hidden jso5AccordionAnswer" role="region" qa_handles="o5-accordion__basic-answer"> <p><span class="o5-text__body-1"><strong>Dental Enrollment Forms</strong></span></p> <p><strong>Dental Select Form - CX093</strong></p> <p><a href="/content/dam/business/support/enrollment-forms/CX093.pdf">Download</a></p> <p><strong>United Healthcare Dental Form - 52133</strong></p> <p><a href="https://workflow.changehealthcare.com/AppNet/UnityForm.aspx?d1=AQyd8q5WNj%2fRjLLNLAx5IlZieM6Nq7sfNKtumCtwxQItun7chT5k%2fYcppW8JWr3D6bPS8bcmPKTrV7234p2vG3XdWIJpaJXnBxYEzHP%2fhk1GibVY6IKmSYrj9bd7HG1rmKH0nxFsQ6EvzU12wd8kJFt8luGYzvZr3CNa0ax%2bM6uUSI01%2bLtf1sMjba6s8hq9lytLkTEvbcoJ8RcKiihAeCBXryT335Za6%2bg%2bmggXdxOihx9ArRyIFk5KeTOdpFVADA%3d%3d" target="_blank" rel="noopener noreferrer">Download</a></p> <p><strong>Aspen Dental - CB141</strong></p> <p><a href="https://workflow.changehealthcare.com/AppNet/UnityForm.aspx?d1=ASMcp%2fhZ6N5Po2RidVBg8XMUcn8CJrMVMY9cb2RqyqhsGmGCchTJoYhzedC3K7S0pqlW9jJj5ls2BaTsvMLMPH8s%2ble8uZVGTqPbVOQlVyZ736aQe9mZ%2b9Phtz%2fM6OJG8Ik%2fpmMOz6DMXEzT8uLjcb3xsLJqmAYD9FGsvrejGU3VO77nhQuXwB19moUk9VCvDW9PWUHuXKXRsiELJZEGzk1uIV5TX4IKia14X%2fkspsjZKcyxUK4z5ZxbmjxUSIhk7Q%3d%3d" target="_blank" rel="noopener noreferrer">Download</a></p> </div> </div> </div> </section> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </main> <div class="o5-Back-to-Top aem-GridColumn aem-GridColumn--default--12"><div id="o5-Back-to-Top" class="o5-Back-to-Top" data-optum-cmp="o5-Back-to-Top" qa-handles="o5-Back-to-Top"> <div class="o5back-top fixed hidden" id="back-top-fixed"> <a href="#main-content" class="back-to-top back-top-fixed" qa-handles="back-top-fixed"> <span class="material-symbols-rounded back-top__arrow" aria-hidden="true">keyboard_arrow_up</span> <span class="assistText-new">back to top</span> </a> </div> <div class="o5back-top static" style="visibility: hidden" qa-handles="back-top-static"> <span id="back-top-static" class="back-to-top static" style="visibility: hidden"> <span class="assistText-new">back to top</span> <span class="material-symbols-rounded back-top__arrow" aria-hidden="true">keyboard_arrow_up</span></span> </div> </div></div> <div class="o5-footer-container aem-GridColumn aem-GridColumn--default--12"> <footer> <div> <div class="o5-footer__withborder"></div> <div class="o5-footer__wrapper dmp-container" qa_handles="o5-FooterContainer"> <div class="o5-footer__row dmp-row" role="navigation" aria-label="Footer"> <div class="dmp-col-lg-12 dmp-col-xl-2" qa_handles="o5-Footer-card"> <div class="o5-footer__column"> <div class="o5-footer__child"> <p id="Company-61563" class="o5-footer__heading"> Company </p> <ul aria-labelledby="Company-61563" class="o5-footer__list"> <li class="o5-footer__item"> <a href="https://www.optum.com/en/about-us.html" class="o5-footer__link"> <span class="o5-footer__text">About us</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.com/en/careers.html" class="o5-footer__link"> <span class="o5-footer__text">Careers</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.com/en/more-optum-sites.html" class="o5-footer__link"> <span class="o5-footer__text">More Optum sites</span> </a> </li> </ul> </div> </div> </div> <div class="dmp-col-lg-12 dmp-col-xl-2" qa_handles="o5-Footer-card"> <div class="o5-footer__column"> <div class="o5-footer__child"> <p id="Support-30958" class="o5-footer__heading"> Support </p> <ul aria-labelledby="Support-30958" class="o5-footer__list"> <li class="o5-footer__item"> <a href="/en/support.html" class="o5-footer__link"> <span class="o5-footer__text">Business support</span> </a> </li> </ul> </div> </div> </div> <div class="dmp-col-lg-12 dmp-col-xl-2" qa_handles="o5-Footer-card"> <div class="o5-footer__column"> <div class="o5-footer__child"> <p id="Countries-66576" class="o5-footer__heading"> Countries </p> <ul aria-labelledby="Countries-66576" class="o5-footer__list"> <li class="o5-footer__item"> <a href="https://www.optum.com.br/" class="o5-footer__link"> <span class="o5-footer__text">Optum Brazil</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.in/" class="o5-footer__link"> <span class="o5-footer__text">Optum India</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.ie/" class="o5-footer__link"> <span class="o5-footer__text">Optum Ireland</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.co.uk/" class="o5-footer__link"> <span class="o5-footer__text">Optum United Kingdom</span> </a> </li> </ul> </div> </div> </div> <div class="o5-footer__column dmp-col-lg-12 dmp-col-xl-2" qa_handles="o5-FooterAccessibilty-Card"> <div class="o5-footer__child"> <p id="Accessibility-83068" class="o5-footer__heading"> Accessibility </p> <ul aria-labelledby="Accessibility-83068" class="o5-footer__list"> <li class="o5-footer__item"> <a href="https://www.optum.com/en/language-assistance-nondiscrimination.html" class="o5-footer__link"> <span class="o5-footer__text" lang="en">Language Assistance / Non-Discrimination Notice</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.com/en/language-assistance-nondiscrimination.html" class="o5-footer__link"> <span class="o5-footer__text" lang="es">Asistencia de Idiomas / Aviso de no Discriminación</span> </a> </li> <li class="o5-footer__item"> <a href="https://www.optum.com/en/language-assistance-nondiscrimination.html" class="o5-footer__link"> <span class="o5-footer__text" lang="zh-CN">語言協助 / 不歧視通知</span> </a> </li> </ul> </div> </div> </div> </div> </div> <div> <div class="o5-legal"> <div class="dmp-container" qa_handles="o5-SocialBar"> <div class="dmp-row"> <div class="social-info"> <nav aria-label="Social"> <p id="social-links" class="o5-legal__follow">Follow us</p> <ul class="o5-legal__social"> <li class="o5-legal__icons"> <a aria-labelledby="social-links linkedin" class="o5-legal__circle" href="https://www.linkedin.com/company/optum"> <span id="linkedin" class="assistText">  on linkedin </span> <img class="linkedin-img" src="/content/dam/optum5/socialshareicons/Linkedin_5a.svg" aria-hidden="true"/>  </a> </li> <li class="o5-legal__icons"> <a aria-labelledby="social-links facebook" class="o5-legal__circle" href="https://www.facebook.com/myOptum/"> <span id="facebook" class="assistText">  on facebook </span> <img class="facebook-img" src="/content/dam/optum5/socialshareicons/Facebook_5a.svg" aria-hidden="true"/>  </a> </li> <li class="o5-legal__icons"> <a aria-labelledby="social-links twitter" class="o5-legal__circle" href="https://twitter.com/optum/"> <span id="twitter" class="assistText">  on twitter </span> <img class="twitter-img" src="/content/dam/optum5/socialshareicons/Twitter_5a.svg" aria-hidden="true"/>  </a> </li> <li class="o5-legal__icons"> <a aria-labelledby="social-links instagram" class="o5-legal__circle" href="https://www.instagram.com/optum/?hl=en"> <span id="instagram" class="assistText">  on instagram </span> <img class="instagram-img" src="/content/dam/optum5/socialshareicons/Instagram_5a.svg" aria-hidden="true"/>  </a> </li> </ul> </nav> </div> <hr class="o5-legal__hr"/> <div class="o5-legal__copyright" qa_handles="o5-LegalBar"> <div class="o5-legal__info"> <p class="o5-legal__copyrighttext">© 2024 Optum, Inc. All rights reserved. Stock photos used.</p> <nav aria-label="Legal"> <ul class="o5-legal__list"> <li> <a target="_self" class="o5-legal__links" href="https://www.optum.com/en/privacy-policy.html"> <span class="o5-legal__text">Privacy policy</span> </a> </li> <li> <a target="_self" class="o5-legal__links" href="https://www.optum.com/en/terms-of-use.html"> <span class="o5-legal__text">Terms of use</span> </a> </li> <li> <a target="_self" class="o5-legal__links" href="https://www.optum.com/en/opt-out.html"> <span class="o5-legal__text">Opt out</span> </a> </li> <li> <a target="_self" class="o5-legal__links" href="https://www.optum.com/en/accessibility.html"> <span class="o5-legal__text">Accessibility</span> </a> </li> <li> <a target="_self" class="o5-legal__links" href="https://www.optum.com/en/vulnerability.html"> <span class="o5-legal__text">Vulnerability report</span> </a> </li> <li> <a target="_self" class="o5-legal__links" href="https://www.optum.com/en/do-not-call-policy.html"> <span class="o5-legal__text">Do Not Call policy</span> </a> </li> </ul> </nav> </div> </div> </div> </div> </div> </div> <script type="text/javascript"> var pagePath = window.location.pathname; if(pagePath.includes("/content/optum-united-kingdom/en_gb") || pagePath.includes("/content/optum-ireland/en-ie")) { document.write("<div id='consent_blackbar'></div>"); document.write("<div id='teconsent'></div>"); var scr = document.createElement("script"); scr.src = '//consent.trustarc.com/notice?domain=uhg-optum.com&c=teconsent&js=nj&noticeType=bb&text=true&privacypolicylink=' + window.location.origin + '/privacy-policy.html'; scr.async = "async"; scr.crossorigin = 'crossorigin'; document.getElementById("teconsent").appendChild(scr); } document.querySelectorAll('.o5-footer__heading').forEach((idx, el) => { var columnId= idx.getAttribute('id'); idx.closest('nav').setAttribute('aria-labelledby', columnId); }); </script> </footer> </div> </div> </div> </div> <script> var digitalData = digitalData || []; digitalData.push( { event: 'pageID', ID: "page\u002D867265861e", }, { event: 'pageTitle', title: "Medical, Hospital and Dental Enrollment Forms | Optum Business", } ); </script> <script> var digitalData = digitalData || []; digitalData.push({ event: 'pageView', page : { pageName : "Medical, Hospital and Dental Enrollment Forms | Optum Business" === "" ? undefined : "Medical, Hospital and Dental Enrollment Forms | Optum Business", pageTitle : "Medical, Hospital and Dental Enrollment Forms" === "" ? undefined : "Medical, Hospital and Dental Enrollment Forms", pageType : "Support" === "" ? undefined : "Support", businessUnit : "" === "" ? undefined : "", funnelStage : "" === "" ? undefined : "", audience : "" === "" ? undefined : "", contentType : "" === "" ? undefined : "", contentFormat : "Webpage text" === "" ? undefined : "Webpage text", productTypes : "" === "" ? undefined : "", whatWeDo : "" === "" ? undefined : "", productCategory : "" === "" ? undefined : "", hubType : "" === "" ? undefined : "", server : "" === "" ? undefined : "", publishedDate : "2024-11-13T03:05:04.847Z" === "" ? undefined : "2024-11-13T03:05:04.847Z", contentTag : "Support|Webpage text" === "" ? undefined : "Support|Webpage text", image : "" === "" ? undefined : "", description : "Find forms for medical claims, patient eligibility, ERA, and EFT payment information." === "" ? undefined : "Find forms for medical claims, patient eligibility, ERA, and EFT payment information.", } }); </script> <script src="/etc.clientlibs/dmp/clientlibs/clientlib-react.lc-53d1e00dc56035b0752f8b6797c46029-lc.min.js"></script> <script src="/etc.clientlibs/dmp/clientlibs/clientlib-site.lc-9136efd11c4ed1ad578dcdff0fb113bc-lc.min.js"></script> <script async src="/etc.clientlibs/core/wcm/components/commons/site/clientlibs/container.lc-0a6aff292f5cc42142779cde92054524-lc.min.js"></script> <script async src="/etc.clientlibs/dmp/clientlibs/clientlib-base.lc-9a7c5c4c30740ce53f09786411afe541-lc.min.js"></script> <script src="https://assets.sitescdn.net/answers-search-bar/v1.0/answerstemplates.compiled.min.js"></script> <script type="text/javascript"> CQ_Analytics.TestTarget.maxProfileParams = 11; if (CQ_Analytics.CCM) { if (CQ_Analytics.CCM.areStoresInitialized) { CQ_Analytics.TestTarget.registerMboxUpdateCalls(); } else { CQ_Analytics.CCM.addListener("storesinitialize", function (e) { CQ_Analytics.TestTarget.registerMboxUpdateCalls(); }); } } else { // client context not there, still register calls CQ_Analytics.TestTarget.registerMboxUpdateCalls(); } </script> </body> </html>

CINXE.COM

Medical, Hospital and Dental Enrollment Forms | Optum Business