Get Optum Auto No-fault Ancillary Referral Form

The Optum Auto No-Fault Ancillary Referral Form is a straightforward document designed to help users submit referrals for various ancillary products and services effectively. By following the steps outlined in this guide, users can confidently complete and submit the form online.

Follow the steps to fill out the form accurately and efficiently

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Identify the 'Claim Type' section to select whether this is a new claim or an existing claim. Choose the appropriate option based on your situation.
3. In the 'Referral Source' section, provide your name in the field marked with an asterisk (*) as this is a required field. Enter your email address to receive confirmation of the referral submission.
4. Complete the 'Company Name' and 'Phone Number' fields if applicable. Indicate your relationship to the claimant by selecting from the provided options: Claims Professional, Case Manager, or Other.
5. Proceed to 'Claimant Information' and fill in the claimant's name, date of birth, and phone number, ensuring all fields marked with an asterisk (*) are filled out.
6. Continue with the claimant's street address, city, state, zip code, height, weight, and preferred language as applicable.
7. In the 'Claim Information' section, enter the adjuster's name, claim number, insurance carrier or third-party administrator (TPA), date of injury, and state of injury/jurisdiction. Each of these fields marked with an asterisk (*) is mandatory.
8. Fill in the physician's details, including name, license number, address, city, state, zip code, and phone number as applicable.
9. Provide the diagnosis code or specify the body part/nature of the injury in the designated space.
10. Select the services needed from the list provided. You can choose multiple options depending on the requirements.
11. Enter the required date for services and any additional comments in the respective fields.
12. Once all fields are completed, review the information for accuracy. You can then either save your changes, download, print, or share the form as needed.

Complete your Optum Auto No-Fault Ancillary Referral Form online today to ensure timely processing.