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Disclosure of ownership form caqh

Optum provider disclosure form 2026

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4.8 out of 5

140 votes

The document outlines the requirements for Individual Providers participating in Medicaid and CHIP managed care programs through Optum. It mandates the disclosure of ownership, controlling interests, management information, and criminal conviction history. Providers must submit a detailed statement including personal and business information, which is necessary for credentialing and enrollment. The form must be updated every three years or upon request, with failure to comply potentially leading to denial of participation or claims.

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Click ‘Get Form’ to open the Optum Provider Disclosure Form in the editor.
Begin by filling out the 'Individual Provider Information' section. Ensure every field is complete, including your name, contact details, and category selection.
Proceed to Section I and provide ownership information. List all individuals or organizations with a Direct or Indirect Ownership Interest of 5% or more in your practice.
In Section II, identify all individuals and entities with a controlling interest. Include officers, directors, and any business partners.
Continue through Sections III to VIII, providing detailed information about ownership interests in other entities, familial relationships, managing employees, criminal convictions, and significant business transactions as required.
Review all entries for accuracy. Attach any necessary documentation as indicated on the form.
Finally, sign the form at the bottom to certify that all provided information is true and complete before submitting it.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (140 Votes)
2015	4 Satisfied (62 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is Optum claims recovery?

The multi-tiered recovery solution from Optum is a relationship-oriented approach that reconciles existing errant claims while meeting cost-containment goals.

What is the PDR form for Optum?

This form is designed for providers to submit disputes related to claims. It provides necessary instructions and requirements for successful submission. Fill out the requested fields accurately to ensure a smooth resolution process.

How do I request medical records from Optum?

Call customer service at the telephone number located on your health plan ID card and ask that we mail or email a Request for Access to Protected Health Information form to you. The form will provide further instructions for completion and where to send it to obtain your records.

What is the EAP modifier for Optum?

Billing for EAP sessions Any session you submit while there are EAP sessions available on the account will be automatically submitted as an EAP using the HJ modifier required by Optum. After all EAP sessions are used, the clients regular insurance benefits will process automatically.

What is Optum in-office assessment program?

The in-office assessment program is a flexible prospective in-office and telehealth2 provider engagement program. It offers a provider-first model of collaboration, actionable data and interactive technology enabling better risk and quality outcomes for members, providers and health plans.

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What is a disclosure of ownership form?

It helps ensure providers have not been unfairly barred from providing services under any federal health care program. It also helps ensure that Medicaid providers do not have relationships with individuals or entities that have been excluded or terminated from participating in any federal health care program.

Optum provider disclosure form 2026

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