Optum Specialty Provider Portal Access Request

There are 0 fields that need to be corrected

Show all errors

Fields marked with an asterisk

*

are required.

Title

Dr, Mr, Mrs

First name

Last name

Healthcare professional type

Prescriber

Non Prescriber

Email

name@email.com

Verify Email

name@email.com

Phone

555-555-5555

Practice name

Provider specialty type

5-digit ZIP code