NOTE: THIS FORM IS NOT TO BE USED TO GAIN ACCESS TO SUBMITTING ELECTRONIC REFERRALS PHYSICIAN INFORMATION PORTAL ACCESS FORM

Physician Name * Address * City * Zip * * Invalid Zip Code	Indicate Region/Area * Indicate a Region/Area R1:Pasadena/SGV/PA R2:Los Angeles   R3:South Bay R4:Long Beach R5:SFV/Santa Clarita R6:Talbert/ARTA R7:Riverside San Jose Magan Optum Care Network-AppleCare
Physician Telephone Number    ** Invalid Phone #. (XXX)XXX-XXXX Fax Number ** Invalid Phone #. (XXX)XXX-XXXX Practice / Group name	Select Request Type: (select all that apply) Staff PCP Specialist * Select at least one type at left * Select at least one type below New Access Update Report Access Add/Remove Access Update Phone/ Address/Email

Please do not print from browser:Upon completion, Click the "Print Portal Access Form" button and Print the PDF.

Physician / Staff Name		Email Address		Physician NPI		Signature		Existing Username Optum-Connect		Cap Report	Adds/Terms (AC only)
		* Invalid e-mail address.				Sign After Printing				Yes No	Yes No
		* Invalid e-mail address.				Sign After Printing				Yes No	Yes No
		* Invalid e-mail address.				Sign After Printing				Yes No	Yes No
		* Invalid e-mail address.				Sign After Printing				Yes No	Yes No
Clinicians or designees understand that the use of Health Insurance Portability and Accountability Act (HIPAA) standards is intended to provide enhanced protections for individually identifiable health information. Clinicians or designees also understand they will be expected to comply with these standards and to use, protect, and disclose Protected Health Information (PHI) only in accordance with the scope of their duties. Unauthorized release or use of PHI will result in performance improvement action, up to and including termination of contract.
Clinicians or designees further understand that the HIPAA security regulations address PHI in electronic format, to include portable and desktop computers (both hardware & software) or any other device capable of receiving or transmitting PHI. Clinicians or designees assume responsibility for the security of the devices and confidentiality of the PHI within his/her scope of control. Clinicians or designees will take reasonable steps to mitigate incidental disclosures and report to the appropriate supervisor any unauthorized disclosure, or potential of disclosure, of protected health information (e.g. theft of laptop, unauthorized access or log in, etc.).
Clinicians or designees recognize that the unauthorized release of certain trade secret information is detrimental to the interests of Optum. Such information includes, but is not limited to, business strategies, technology and technical data, patient lists, contracts and information regarding contract negotiations, concepts, clinical research protocols, data, and agreements, materials, product design, formulae, marketing data and plans, financial data, and any intellectual property therein or related thereto. Trade secret information is a special, valuable and unique asset of Optum, therefore, clinicians and their designees are expected to safeguard all of Optum’s trade secrets, and the unauthorized release of any information therein or related thereto is strictly prohibited.
WHEN AN AUTHORIZED USER IS NO LONGER PART OF YOUR OFFICE PRACTICE, YOU WILL NEED TO UPDATE THE OPTUM CONNECT PHYSICIAN PORTAL ACCESS FORM WITH THE TERMINATION DATE AND YOUR INITIALS (OR YOUR DESIGNEE FROM THE PRACTICE), AND SUBMIT IT TO CSD SO THAT WE CAN TERMINATE THAT USER’S ACCESS.