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? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | prescription fax form, optumrx order form, optum rx fax, optumrx fax order form |
New Prescription Fax Order Form
1Please fill out Section 1, then have your physician fill out Section 2 and FAX it to
NOTE: THIS FAX IS VOID UNLESS RECEIVED DIRECTLY FROM YOUR PHYSICIAN’S OFFICE.
Primary Member ID Number |
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(Additional coverage, if applicable) |
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Secondary Member ID Number |
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Last Name |
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First Name |
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MI |
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Delivery Address |
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Apt. # |
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City |
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State |
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ZIP |
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Phone Number with Area Code |
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Date of Birth (mm/dd/yyyy) |
Gender |
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M |
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F |
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Medication Allergies: |
NONE KNOWN |
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Health Conditions: |
None Known |
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Amoxil/Ampicillin |
Erythromycin |
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Sulfa |
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Arthritis |
Glaucoma |
Osteoporosis |
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Aspirin |
NSAIDs |
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Tetracyclines |
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Asthma |
Heart Condition |
Thyroid Disease |
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Cephalosporins |
Penicillin |
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Others: |
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Cancer |
High Blood Pressure |
Others: |
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Codeine |
Quinolones |
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Diabetes |
High Cholesterol |
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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
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 |
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Refills |
1 |
2 |
3 |
Other: |
Dispense as written |
Yes |
Physician Name |
Office Phone Number with Area Code |
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Street Address |
Fax Number with Area Code |
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City, State, ZIP |
NPI |
DEA |
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Physician Signature |
Date |
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ORX5510FE_120601