Fillable Request for Participation

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Request for Participation

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The Request for Participation form is 2 pages long and contains:

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  • 12 check-boxes
  • 13 other fields

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File type: PDF

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V: 12_2020
Request for Participation
This form should only be completed if you do NOT have a current Agreement with Optima
Health. If you are currently contracted, and you are adding a practitioner to your agreement,
please complete the Provider Update form.
Complete the following information and email the form to: PrvRecruit@sentara.com
.
Once received, Network Management will evaluate services provided and present to the
Steering Committee for final determination. If approved, you will receive the appropriate
applications for participation. The Steering Committee meets once a month.
Demographic Information:
Legal Name:
Group NPI:
Tax Identification Number:
Provider Type:
(Behavioral Health Practitioner Group,
Medical Practitioner Group, Facility,
Organizational Provider*)
Specialty:
Specific Services Offered:
(PCP or specialist type services, DME, etc)
Primary Address, including City/State
Phone and Fax:
Contact Name:
Email Address:
*Organizational Provider is a group of practitioners or entity that only bills at the Group NPI
level. Examples, include, but are not limited to: Ambulance, Audiology, PT/OT/ST,
Durable Medical Equipment, Dialysis Center, Home Health, ARTS, CMHRS, etc.
Contract Information:
Name of the Individual with Signing
Authority for the Group:
Title:
Contract Mailing Address (if
different from above)
Attach any additional information that would assist Network Management in the evaluation
process.
Providers offering Long Term and Support Services (Respite Care, Personal Care, Personal Emergency
Response, Environmental Modifications, etc.), please contact Centipede at joincentipede@heops.com.
Providers offering Long Term and Support Services (Respite Care, Personal Care, Personal Em
ergency
Response, Environmental Modifications, etc.), please contact Centipede at joincentipede@heops.com.
V: 12_2020
Service Area:
Check one or more of the service areas that you are able to provide services.
☐ Entire SHP Service Area (all service areas in the Commonwealth of Virginia, Kentucky,
Maryland, North Carolina, Tennessee, and West Virginia)
Virginia Regions:
☐ Tidewater Region: Accomack, Chesapeake City, Gloucester, Hampton City, Isle of Wight,
James City, Newport News City, Norfolk City, Northampton, Poquoson City, Portsmouth City, Suffolk
City, Surry, Virginia Beach City, Williamsburg City, York
☐ Central Region: Amelia, Brunswick, Caroline, Charles City, Chesterfield, Colonial Heights City,
Cumberland, Dinwiddie, Emporia City, Essex, Franklin City, Fredericksburg, Goochland, Greensville,
Hanover, Henrico, Hopewell City, King and Queen, King George, King William, Lancaster, Lunenberg,
Mathews, Mecklenburg, Middlesex, New Kent, Northumberland, Nottoway, Petersburg City, Petersburg
City, Powhatan, Prince Edward, Prince George, Richmond City, Southampton, Spotsylvania, Stafford,
Surry, Sussex, Westmoreland
☐ Northern Virginia and Valley Region: Alexandria City, Arlington, Clarke, Culpeper, Fairfax,
Fairfax City, Falls Church City, Fauquier, Frederick, Loudoun, Manassas City, Manassas Park City,
Page, Prince William, Rappahannock, Shenandoah, Warren, Winchester
☐ Western Region: Albemarle, Amherst, Appomattox, Augusta, Buckingham, Campbell,
Charlotte, Charlottesville, Danville, Fluvanna, Greene, Halifax, Harrisonburg, Louisa, Lynchburg,
Madison, Nelson, Orange, Pittsylvania, Staunton, Waynesboro
☐ Roanoke Region: Alleghany, Bath, Bedford, Botetourt, Buena Vista City, Covington City,
Craig, Floyd, Franklin, Giles, Henry, Highland, Lexington City, Martinsville City, Montgomery, Patrick,
Pulaski, Radford City, Roanoke, Roanoke City, Rockbridge, Salem City, Wythe
☐ Southwest Region: Bland, Bristol City, Buchanan, Carroll, Dickenson, Galax City, Grayson,
Lee, Norton City, Russell, Scott, Smyth, Tazewell, Washington, Wise
☐ Kentucky (All contiguous counties to Virginia)
☐ Maryland (All contiguous counties to Virginia)
☐ North Carolina (All contiguous counties to Virginia)
☐ Tennessee (All contiguous counties to Virginia)
☐ West Virginia (All contiguous counties to Virginia)
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Request for Participation

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Completed 19 December 2021

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