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S OFFICE. Primary Member ID Number (Additional coverage, if applicable) Secondary Member ID Number First Name Last Name MI Delivery Address Apt. # City State ZIP Date of Birth (mm/dd/yyyy) Gender Email M Medication Allergies: / Aspirin Cephalosporins Codeine NSAIDs Quinolones Phone Number with Area Code F Health Conditions: None Known Sulfa Tetracyclines Others: Arthri.

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Related content

New Prescription Physician Fax Order Form - Optum...
Physician. X_______________________________________. Signature. Date. ______. Physician to...
Learn more
OptumRx New Prescription Physician Fax Order Form...
Physician to fax completed order form to optumrx at 1-800-491-7997. 1. 2. 3...
Learn more

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Upload your document. Select the recipient's country and enter the recipient's fax number. Sign up and purchase fax tokens if required. Click on the Send button to confirm your fax.

A large portion of your drug spend is attributed to maintenance medications. That's why it is important to take advantage of a powerful solution OptumRx® Mail Service Pharmacy. Driving mail service utilization may reduce costs for you, and lead to greater savings for your employees and plan members.

Physician to fax completed order form to OptumRx at 1-800-491-7997.

OptumRx and BriovaRx are subsidiaries of UnitedHealth Group. UnitedHealthcare and the dimensional U logo are trademarks of UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.

(March 17, 2016) OptumRx and Walgreens are partnering to create a new pharmacy solution to meet consumers' changing prescription drug needs and help employers, health plans and their members achieve better health outcomes and greater cost savings.

Commercial: 1-855-842-6337. Medicare Prescription Drug Plan Members (PDP): 1-877-889-5802. Medicare Advantage Prescription Drug plan members (MAPD): 1-877-889-6358.

OptumRx is UnitedHealth Group's [NYSE: UNH] free-standing pharmacy care services business, managing more than one billion prescriptions annually. Walgreens is one of the nation's largest drugstore chains and part of the Retail Pharmacy USA Division of Walgreens Boot Alliance, Inc. [Nasdaq: WBA].

Contact ORxProviderHelp@optum.com or call 1-800-791-7658. Send us a complete prescription using the Physician Fax Form. Questions? Provide a verbal prescription directly to an OptumRx pharmacist dedicated to our health care providers.

You can cancel your automatic refill, or update the ship date, at www.optumrx.com.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232