Get Prior Authorization Request Form - Optumrx

The Prior Authorization Request Form - OptumRx is an essential document for healthcare providers seeking approval for medications. This guide is designed to help users navigate the process of completing the form online efficiently and accurately.

Follow the steps to complete the Prior Authorization Request Form - OptumRx online.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form and open it in your preferred document editor.
2. Begin by filling out the member information section. Enter the member's name, insurance ID number, date of birth, address, apartment number, city, state, zip code, phone number, alternate phone, and gender.
3. Next, complete the provider information section. Provide the provider's name, National Provider Identifier (NPI), address, city, state, suite number, building number, phone number, zip code, fax number, and the provider's specialty.
4. In the medication information section, fill in the medication name, strength, and directions for use. Indicate whether the medication is a new start and provide the appropriate ICD9 code and diagnosis.
5. If the medication is not a new start, include the initiation date and the date of last dose.
6. For the administration instructions, indicate whether the medication is self-administered, provided by home health, or other means. Specify if the physician is supplying the medication.
7. Review the supporting documentation requirements and ensure that any necessary statements are included with your submission.
8. Once all sections of the form are filled out, save your changes. You can then download, print, or share the form as needed.

Complete your Prior Authorization Request Form online today for a smoother submission process.