Vendor/Provider Name: *

Tax ID #: *

Contact Name (Include First & Last Name) *

Email Address: *

Phone Number: *

Do you have a current Optum Connect (Claims Portal) Account? *

Yes

No

Unsure

Username (OHID):

Briefly describe the reason you are contacting us?: *
Provide the following required information to expedite your request:
A. Check Details (Check#, Check Date & Amount)
B. Claim Details (Member Name, DOB & DOS)
C. Signed Copy of the Access Form
D. Copy of the ERA Enrollment Form

Attachments:
Attach screenshots, error message, or documents that help explain the issue or request.

Send me a copy of my Report Issue Form? *

Yes

No