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Get OPTUM Rheumatology Enrollment Form 2020-2024

Please complete the following or send patient demographic sheet Prescriber s Name Patient Name DEA Address NPI Address 2 Group / Hospital Address City, State, Zip Home Phone DOB Last Four of SS# Language Preference: English Spanish Alternate Phone City, State, ZIP Gender Phone Fax Contact Person Phone Other INSURANCE INFORMATION (Must fax a copy of patient s insurance card including both sides) Prior Authorization Reference number: MEDICAL INFORMATION (Section must be.

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