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Get OptumRx Prior Authorization Request Form 2018

E service. Please note: All information below is required to process this request. Mon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific Prior Authorization Request Form DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information (required) Provider Information (required) Member Name: Provider Name: Insurance ID#: NPI#: Date of Birth: Office Phone: Street Address: Office Fax: City: State: Phone: Zip: Specialty: Office Street Address: City: S.

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