Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to obtain the form and access it in the online editor.
2. Begin by entering patient information, including the patient’s name, insurance ID, date of birth, height, weight, address, phone numbers, and sex. Ensure that all fields are completed accurately to avoid delays.
3. Proceed to the provider information section. Fill in the provider’s name, ID number, address, city, suite number, phone number, fax number, state, zip, and specialty. This information is vital for the authorization process.
4. Next, input medication information. Fill in the medication name, quantity, ICD9 code, directions for use, diagnosis, and refill information. Ensure accuracy in this section to support the rationale for authorization.
5. Collect the physician's signature. The signature authorizes OptumRx to process the prescription. Remember that if the physician is directly supplying the medication, a signature may not be required.
6. Indicate whether the patient has been instructed on how to self-administer the medication and if this is a new start. If it is not a new start, provide the initiation date and the date of the last dose.
7. Add delivery instructions. Specify where the medication should be sent, such as the physician’s office or the patient’s address. Complete the details for the delivery requirements.
8. Select applicable combination medications and specialists who are prescribing or recommending the medication for the patient. Document the patient's diagnosis and any related background.
9. Indicate any concurrent medications, including history of trials, failures, contraindications, or intolerances. This information may require additional documentation.
10. At the final step, review all the entered information for accuracy. Once confirmed, you can save changes, download the completed form, print it, or share it as necessary.

Start completing the Prior Authorization Request Form online now for a smooth submission process.