Network Participation Request form

Site Logo

Support
Contact our sales team

Provide your contact details below, so one of our product specialists can schedule a call.

Need help or account access? View our support resources or sign in.

Get in touch

Contact our sales team
Connect with us for solutions or services.

Customer sign-in
Access our customer portals.
Optum Provider Portal   Optum Pay All Sign-in Portals

Support and resources
Manage your account, find resources and more.
Payer lists   Enrollment forms   Product Support portals   Claims
Rx Prior Authorization   Join Our Team   All Support

Submission instructions:

Download the PDF form and submit vie one of the following:

Email: independent.contracting@optum.com
Fax: 1-844-305-2623

Related resources

PDF

Provider Network Participation Request Form

Download the form

back to top