Get Enrollment Form

Completing the Enrollment Form online is an essential step for UnitedHealthcare members seeking a prescription for . This guide will provide clear instructions on how to navigate each section of the form, ensuring you have all the necessary information for a smooth submission process.

Follow the steps to complete your enrollment form effectively.

1. Click ‘Get Form’ button to access the enrollment form and open it in your browser.
2. Fill in the date fields at the top of the form, including the current date and the date by which you need the prescription.
3. Provide the patient information, including the patient's name, insurance ID number, guardian's name, contact numbers, address, and date of birth in the specified format.
4. Attach any necessary medical records or summaries that demonstrate the patient's diagnosis. Ensure you include the relevant ICD codes and diagnoses.
5. Complete the clinical information section by answering the questions about the patient’s conditions and treatments, indicating whether they have experienced any symptoms or treatment failures.
6. In the prescription information area, specify the medication details, including strength, directions, quantity, and refill information for .
7. For prescriber information, fill in the prescriber’s name, DEA, contact details, and obtain their signature and date acknowledgment.
8. Complete the insurance information by providing details for both primary and secondary insurance, including the insurer's names, ID numbers, and subscriber information.
9. Review the completed form for any missing information that could delay the processing. Once complete, save your changes.
10. You can now fax the completed form to OptumRx at the provided number, or download and print a copy for your records.

Start filling out your Enrollment Form online today!