Home
Forms Library
FACILITY AGENCY APPLICATION

FACILITY AGENCY APPLICATION 2025

FACILITY AGENCY APPLICATION Preview on Page 1

See details

4.3 out of 5

50 votes

The document is a Facility Network Request Form and Credentialing Application for Optum/OptumHealth Behavioral Solutions of California. It outlines the application process for facilities seeking to join the Optum network, detailing required information, documentation, and compliance standards necessary for credentialing. The form includes sections for organizational information, levels of care desired, accreditation details, legal status inquiries, and service delivery specifics. It emphasizes the importance of thorough completion to avoid delays in processing.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out FACILITY AGENCY APPLICATION with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the FACILITY AGENCY APPLICATION in the editor.
Begin by completing Pages 2-6, ensuring all fields are filled thoroughly. Pay special attention to the signature section on Page 6, where the authorized individual must attest to the information provided.
For new facility applicants, proceed to Pages 7-10. Fill out all required sections, indicating 'N/A' for any non-applicable components to avoid leaving blanks that could delay processing.
In the Organizational Facility Identifying Information section, provide accurate details such as legal name, administrative address, and contact information. Ensure that your Tax Identification Number is included.
Identify the levels of care your facility desires to contract by checking appropriate boxes. This includes options like Substance Abuse and Psychiatric/Mental Health services.
Complete the accreditation and licensure sections by providing relevant details about your certifications and licenses. Attach necessary documentation as specified in the checklist.

Start using our platform today for free to streamline your FACILITY AGENCY APPLICATION process!

See more FACILITY AGENCY APPLICATION versions

We've got more versions of the FACILITY AGENCY APPLICATION form. Select the right FACILITY AGENCY APPLICATION version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (239 Votes)
2016	4.3 Satisfied (50 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

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.

How to open a home health agency in SC?

Become a Medicaid Provider Prep for Enrollment: Providers will need a national provider identification (NPI) and taxonomy number. Apply for individual National Provider Identifier (NPI) number. Complete and submit the Medicaid provider enrollment application. SCDHHS will notify providers of successful enrollment.

What is the difference between a home care agency and a home health agency?

Home health provides clinical care to help the patient recover, and home care helps with day-to-day caregiving and tasks. Some agencies provide both home health care and home care.

How to start a home health care business in SC?

How to Start a Home Care Agency in South Carolina Learn the Requirements of Starting a Home Care Agency in South Carolina. Register Your Home Care Business in South Carolina. Obtain an EIN (Employer Identification Number) from the IRS. Write a Business Plan Before You Start a Home Care Agency in South Carolina.

How much does it cost to start a home health agency?

Depending on the location of your home healthcare agency, the estimated start-up costs run as follows: Private Pay Home Care agency: $40,000 to $80,000. Licensed Home Health non-Medicare agency: $60,000 to $100,000. Medicare Certified agency: $150,000 to $350,000.