Get Optum Rx Pa Form

The Optum Rx Pa Form is essential for requesting prior authorization for specific medications. This guide provides step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete the Optum Rx Pa Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by filling out the patient information section. Include the patient's name, insurance ID, date of birth, height, weight, address, phone number, sex, and any alternate contact number.
3. Next, provide the provider's information. Input the provider’s name, provider ID number, address, phone number, and specialty.
4. Complete the medication information section. This includes the medication name, quantity, ICD9 code, directions for use, diagnosis, and refills. Additionally, include the physician's signature and indicate whether the physician will supply the medication.
5. Indicate whether the patient has been instructed on how to self-administer the medication. Answer additional questions regarding medication history, including whether the medication is a new start.
6. Fill out delivery instructions. Ensure that either the physician’s office or the patient's address is specified for medication delivery, including the date the medication is needed.
7. For specific conditions, ensure to provide additional details as required by the form, such as diagnosis history, treatment outcomes, and past medications tried.
8. Review all the filled sections for accuracy. Make necessary corrections before finalizing the form.
9. Once completed, you can save changes, download, print, or share the form as needed.

Start filling out your Optum Rx Pa Form online today for fast processing.