Prescription Fax Order Form 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.

QuestionAnswer
Form NameOptumrx Order Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprescription fax form, optumrx order form, optum rx fax, optumrx fax order form

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