Client Access Request Form - Optum Client Portal Site

Client Access Request Form for Optum Hospice Pharmacy Services

IMPORTANT: This form is only for hospice providers (businesses) of Optum Hospice Pharmacy Services. This form is not for patients or the general public.

Name

This information is required

Title

This information is required

Email Address

This information is required

Phone Number

This information is required

Hospice Name

This information is required

Optum Group Number(s)

This information is required

Do you require access to the Optum Client Portal site (e.g. Hospi U, clinical library, webinars, etc)?

Invalid Input

Do you require access to HospiDirect? (Note: access requires approval of your manager)

Invalid Input

Do you require access to HospiTrac? (Note: access requires approval of your manager)

Invalid Input

If you require access to HospiDirect and/or HospiTrac, please provide your manager’s contact info below:

Provide any additional comments, if needed:

This information is required

NOTE: Optum will respond to your request via email.