Get Optumrx Fillable Enrollment Form

Completing the Optumrx Fillable Enrollment Form online is a straightforward process, designed to streamline the enrollment procedure. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete your enrollment form seamlessly.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the patient information. Fill in the patient’s name, insurance ID, date of birth, height, weight, and address. Ensure all details are accurate to prevent any processing delays.
3. Next, move to the provider information section. Enter the provider’s name, provider ID number, address, specialty, and contact information. This information is essential for verification purposes.
4. In the medication information section, specify the medication name, quantity, ICD-9 code, administration directions, diagnosis, and the number of refills requested. This will help the pharmacy fulfill the prescription correctly.
5. Ensure that the physician signature is provided. This authorizes Prescription Solutions to facilitate the dispensing of the requested medication. Remember, a signature is not needed if the physician supplies the medication directly.
6. Next, complete the medication instructions section by indicating whether the patient has been instructed on how to self-administer the medication and if it is a new start. If it is not a new start, provide the initiation date and the date of the last dose.
7. For delivery instructions, indicate whether the medication should be shipped to the physician’s office or the patient's address and the date when the medication is needed.
8. Finally, review all entries for accuracy and completeness. Once satisfied with the information provided, save any changes made to the document. You can then download, print, or share the completed form as necessary.

Start completing your Optumrx Fillable Enrollment Form online today!