Temporary Funding Inquiry Form

Submit this form for help with eligibility or if the available funds are insufficient to cover the difference between your current claim payments and your pre-incident payments.

Once submitted, we will review your request and be in touch with next steps. If you have questions, please contact us at 1-877-702-3253. Submitting this inquiry form does not guarantee your eligibility nor does it guarantee any funding amount will be received.

Funding amounts are available in weekly allotments. These weekly funding allotments do not automatically renew. Instead, providers must sign into their Optum Pay account and request available funding each week in which they elect to receive program funds. This form must be submitted every 7 days to be considered for additional funding.