Optima Behavioral Health Provider Registration

OBH Provider Connection on OptimaBehavioralHealth.com is a secure environment for providers and their practice staff to access health plan transactions. Please complete the information for each potential Optimabehavioralhealth.com enrollee. Once submitted, the Practice Supervisor/Manager/Provider will receive confirmation of the enrollment.
A member of OBH Provider Services will contact you regarding your login and password.

If you have questions, please contact Provider Services.

*An asterisk denotes required information

*Acceptance Agreement

I acknowledge that the user below is an authorized representative of this practice/facility. I agree to notify OBH promptly of additions or deletions of users. I understand that with the implementation of the online health plan information, our practice will begin receiving documents, manuals, directories and bulletins from OBH online, instead of by mail and/or fax. Paper remits will not be provided when the provider begins to receive payments and remits electronically by means of EFT (Electronic Fund Transfer) / ERA (Electronic Remittance Advice) of eRemits. Download the Electronic Billing Services Agreement
I Agree to the terms listed above.

*Type of Request:

If Account Change please describe type of change:

*Is this a Practice or Billing Company? Check one.
Practice
Billing Company

Part 1: User Login Information

*First Name:

*Middle Initial:

(Use NMN for no middle initial)

*Last Name:

Suffix:

(Jr, Sr, etc)

Title:

(MD, LCP, LPC, LCSW, etc.)

*Date of Birth:

(mm/dd/yyyy)

*SSN:

(xxx-xx-xxxx)

Gender:

Male
Female

Pager Number:

*Business Phone:

Fax Number:

*Email:

N/A

Part 2: Practice or Billing Company Demographic Information

*Name of Practice or Billing Company:

*Address:

*City:

*State:

*Zip Code:

*Telephone:

*Tax ID Number:

Please include the vendor numbers for all practices for which you are requesting access. (Vendor number may be found at the top of the practice's remittance statement)

Vendor Numbers:

Neuropsychological testing performed:

Yes
No

Part 3: Role Information (Select one)

MD
Resident
NP
Clinical (Access to clinical/demographic data)
Administrative/Billing (Access to demographic/billing data)
Administrative/Billing and Clinical (Access to clinical & demographic /billing data)
Contract Billing Company Employee (Complete Part 4)

Part 4: Contract Billing Company Information

Contract Billing Company ONLY: This section applies only if you are a billing company contracted by the physician practice. List the name of all practice(s) for which you provide billing services.

If Contract Billing Company, do you require access to Patient Clinical Data?
Yes
No

If Contract Billing Company, has a Business Associate Agreement between your company and the provider office(s) you represent been filed with Optima Health.
Yes
No

Part 5: Practice Supervisor (i.e., Practice Manager or MD.)

*Supervisor Name:

*Email:

*Telephone: