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Optumrx Order Form PDF Details

If you are in need of prescription medication, you may be wondering how to go about getting your medications. One option is to use an order form from Optumrx. This article will provide an overview of the Optumrx order form so that you can decide if it is the right option for you. First, we will discuss what information you will need to have on hand before completing the form. Then, we will walk through each section of the form and explain what it entails. Finally, we will provide a few tips for completing the form accurately and efficiently.

You can find info about the type of form you need to prepare in the table. It will show you how much time it should take to finish optumrx order form, what fields you will need to fill in and a few further specific details.

Question	Answer
Form Name	Optumrx Order Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	60
Avg. time to fill out	12 min 19 sec
Other names	optumrx new order, prescription fax order form, optumrx new form, optumrx fax order form

12

Form Preview Example

New Prescription Fax Order Form

1Please ﬁll out Section 1, then have your physician ﬁll out Section 2 and FAX it to 1-800-491-7997.

NOTE: THIS FAX IS VOID UNLESS RECEIVED DIRECTLY FROM YOUR PHYSICIAN’S OFFICE.

Primary Member ID Number

(Additional coverage, if applicable)

Secondary Member ID Number

Last Name

First Name

MI

Delivery Address

Apt. #

City

State

ZIP

Phone Number with Area Code

Date of Birth (mm/dd/yyyy)

Gender

Email

M

F

Medication Allergies:

 NONE KNOWN

Health Conditions:

 None Known

 Amoxil/Ampicillin

 Erythromycin

 Sulfa

 Arthritis

 Glaucoma

 Osteoporosis

 Aspirin

 NSAIDs

 Tetracyclines

 Asthma

 Heart Condition

 Thyroid Disease

 Cephalosporins

 Penicillin

 Others:

 Cancer

 High Blood Pressure

 Others:

 Codeine

 Quinolones

 Diabetes

 High Cholesterol

Over-the-counter/Herbal medications taken regularly:

Keep on ﬁle. Do not ship. If you are including any prescriptions that you want to keep on ﬁle for shipment at a later date, please list them here:

Notes to Pharmacy:

2PHYSICIAN —

Please ﬁll out Section 2,

or attach your ofﬁce prescription to this form.

Then FAX to1-800-491-7997

Physician-Only Phone:

1-800-791-7658

This document, including any attachments, contains personal and sensitive information related to a person’s health care. The information contained in this document is intended only for the sole use of OptumRx. If you are not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, you are hereby notiﬁed that any disclosure, copying, distribution or use of the contents of this information is strictly prohibited and will be vigorously prosecuted.

If you have received this document in error, please immediately notify the sender, or OptumRx by phone or fax at the numbers listed above.

Patient Name	DOB

Reﬁlls

1

2

3

Other:

Dispense as written

Yes

Physician Name		Ofﬁce Phone Number with Area Code

Street Address		Fax Number with Area Code

City, State, ZIP		NPI	DEA

Physician Signature		Date

ORX5510FE_120601

How to Edit Optumrx Order Form Online for Free

Our PDF editor helps make completing files simple. It is quite effortless to edit the Optumrx Order Form file. Follow these particular steps if you need to do this:

Step 1: Initially, select the orange "Get form now" button.

Step 2: So, you are able to update your optumrx new order. This multifunctional toolbar makes it possible to add, erase, adapt, highlight, as well as undertake other sorts of commands to the content and fields inside the file.

These particular parts will make up the PDF document:

completing optumrx quick fax form stage 1

Enter the requested information in the area Physician, Name Street, Address City, State, ZIP Physician, Signature OR, XFE Re, ll, s Other, Dispense, as, written Yes, Of, ce, Phone, Number, with, Area, Code Fax, Number, with, Area, Code NP, I Date, and DE, A

stage 2 to completing optumrx quick fax form

Step 3: Press the Done button to make sure that your finalized file could be transferred to any type of electronic device you select or forwarded to an email you specify.

Step 4: To protect yourself from any problems in the long run, you will need to create no less than a couple of duplicates of your file.

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