Get Optumrx Form

Filling out the Optumrx Form online can be a straightforward process if you follow the proper steps. This guide is designed to help you navigate each section of the form with ease and ensure you provide all necessary information accurately.

Follow the steps to complete the Optumrx Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the Member Information section. Input the member's name, date of birth, and insurance ID number. Ensure all details are accurate.
3. Next, provide the Provider Information. Enter the provider's name, office phone, office fax, street address, city, state, zip code, and specialty.
4. In the Medication Information section, enter the medication name, strength, and dosage form. Indicate whether the medication is a new start by selecting 'Yes' or 'No.' Include directions for use.
5. Move on to the Clinical Information. Select the relevant diagnosis from the provided options and fill in the ICD-9/10 code if applicable. Specify any medications the member has failed, has contraindications to, or has shown intolerance.
6. Lastly, use the space provided for any additional comments, diagnoses, symptoms, or other pertinent information that should be included for review.
7. Once you have filled out all the sections, save your changes. You may then choose to download, print, or share the form as necessary.

Start filling out your documents online today!