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N 24/7 Prior Authorization and Specialty Pharmacy Prescription Form Patient Information Patient s Name: Insurance ID: Date of Birth: Height: Address: Weight: Apartment #: City: State: Zip: Phone Number: Alternate Phone: Sex: Male Female Provider Information Provider s Name: Provider ID Number: Address: City: Suite Number: Building Number: Phone Number: Fax number: State: Zip: Provider s Specialty: Medication Information Medication: Directions: Quantity: Diagnosis.

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Related content

Frequently asked questions about your pharmacy...
Download a form from optumrx.com/calpers. Then complete and mail it to OptumRx with your...
Learn more

Related links form

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Contact support

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.

We support specialty treatments and take a hands-on approach to patient care that makes a meaningful imprint on the health and quality of life of each patient. You can count on our guidance, education, and compassion throughout your entire course of treatment.

BriovaRx is changing its name to Optum Specialty Pharmacy and BriovaRx Infusion Services is changing its name to Optum Infusion Pharmacy.

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 and BriovaRx are subsidiaries of UnitedHealth Group. ... Health Plan coverage provided by or through a UnitedHealthcare company.

NASP defines specialty pharmacy as a state-licensed pharmacy that solely or largely provides only medications for people with serious health conditions requiring complex therapies.

Prescription Solutions is now OptumRx one of three key business segments comprising the newly formed Optum . This gives UnitedHealth Group two major brands Optum on the health services side, and UnitedHealthcare representing health care benefits.

We support specialty treatments and take a hands-on approach to patient care that makes a meaningful imprint on the health and quality of life of each patient.

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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