If you don't see the form you’re looking for, please refer to the Optum Pro Portal.
EFT Enrollment Forms (currently unavailable, coming soon)
ePayment/EFT allows providers to receive payments electronically from payers that have contracted with Change Healthcare to perform this service.
Real-time enrollment forms
Real-time functions provide the ability to verify eligibility, check claims status, locate providers, review requests and responses and make claim-related financial inquiries.
Each provider must be set up in the system to access real-time functions.
- New customers: Please contact the sales team regarding real-time products.
- Current customers: Please contact your vendor for assistance.
Commonly used real-time enrollment forms
- CHC MID/TID/TPG Creation Form – Initial request for a MID/TID or TPG
- Real-time NPI Payer Add – Existing Clients – Add additional NPIs
Full list of enrollment forms
Blue Cross & Blue Shield of Delaware
HealthPartners MN
Triple-S Salud
Mapfre
Medical Card System (MCS)
MMM Healthcare
Preferred Medicare Choice (Reform)
Triple-S Advantage
MMM Healthcare (Reform)
Vermont Medicaid VT
California Medi-Cal
Kaiser Permanente
Mountain State Blue Cross of West Virginia
Highmark Blue Cross & Blue Shield of Pennsylvania
Association de Maestros Puerto Rico
First Medical Health Plan (IMC)
Medicare Medex
Preferred Medicare Choice
Nevada Medicaid
Dental (currently unavailable — coming soon)