» » OptumRx Prior (Rx) Authorization Form

OptumRx Prior (Rx) Authorization Form

When a physician wishes to prescribe a non-recommended medication for an OptumRx member, they will have to request coverage by filling and faxing an OptumRx Prior Authorization Form. Below you will find the fax number which you should fax the form to, and a phone contact should you require immediate assistance. For medical services, use the OptumCare Prior Authorization Form which is found here.

How to Write

Step 1 – Begin by filling providing the patient’s name, insurance ID number, date of birth, complete address, and phone number into the Member Information section.

Step 2 – In Provider Information, enter your name, your NPI number, your specialty, your office phone and fax number, and the complete address of your office.

Step 3 – In Medication Information, enter the name, strength, form of dosage, and directions for use of the medication you are requesting coverage for. Next, indicate whether you are requesting a particular brand of drug, whether this is a continuing prescription, and if so, whether the medication has been effective.

Step 4 – Then enter the relevant diagnosis that you have made of the patient into the indicated field. Below that, provide the types and duration of use for any previous medications that your patient has been prescribed for this diagnosis.

Step 5 – Finally, you must attest to the verity of your submitted information, provide your signature, and the date.

Step 6 – If you have any other comments that you would like to be considered, enter them into the indicated area near the bottom of the form.

Related pages

boat registration arkansasfree quit claim deed formsrental lease agreement virginiaboat registration idahopersonal loan promissory note templaterental forms oregonintent to vacate letter templatemassachusetts eviction lawspromissory note format for lending moneysample rental invoiceflorida association of realtors residential leasetowing invoice formsindependent contractor non compete agreementeviction process in pausaa direct deposit pay datesfive day demand notice for nonpayment of rentnon compete for independent contractorbb&t routing number georgiasimple lease templateoptum rx faxalabama residential lease agreementcar rental agreement docapartment lease agreement texashyatt regency credit card authorization formcar leasing agreement templategeorgia rental leaselandlord background check formforming an llc in nevadafree printable living willsapartment lease termination letter samplequick claim deed nevadapaid receipt template wordnjmvc formsrent receipt format downloadtenant lease termination letteremployee disciplinary form templatedeed of trust in californiadurable power of attorney texas free formemployee discipline form templatepa llc operating agreementsc dmv title searchsublet agreement contractloan contracts templatesformat of formal resignation letterbreaking a lease in masamples of recommendation letters for a friend5 day notice to vacate illinoissamples of wills and testamentsexpress scripts prior authorizationplumbing invoicelease agreement alabamaodt georgiarecorder of deeds st louis county moconnecticut secretary of state formsny durable power of attorney formlease agreement florida pdfnotice to vacate washingtonpromissory note texaspromissory note californianotary templatecalifornia assn of realtorsnew mexico secretary of state llctemplate for receipts of paymentprintable rental receiptcancellation of lease agreement formrental agreement minnesotaohio bmv power of attorney formcapital one routing number new york citypa eviction processvt dmv bill of salesublet nj