To submit a request for access to the OptumHealth Client website, you must complete all fields in the form below. Upon approval of your request, we will forward you the OptumID registration link to create your userid and password.
All fields below that are bolded and marked with an asterisk (*) are required fields.
Company Name*:
Site Location*:
Company Type*:
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*:
Enter the name of the group you would like to access on the website*:
Comments
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