Do you need to fax a prescription to Optumrx? If so, you can use the Optumrx Prescription Fax Form. This form is easy to use and allows you to submit your prescription quickly and easily. You can also track the status of your order online. Let's take a closer look at how this form works.
We have compiled some quick details about the optumrx prescription fax form. It's recommended that you read through this info before you start filling out the PDF.
Question | Answer |
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Form Name | Optumrx Prescription Fax Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | optumrx new prescription fax order form printable, optumrx appeal fax number, 800 791 7658, optumrx appeal form |
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5510 |
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Fax: |
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Physician: |
Please provide: |
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Customer Service Phone #: |
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Complete Patient Information |
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Physician's Line: |
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Complete Prescription Information |
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90 day supply is preferred |
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Note: Schedule II medications cannot be faxed |
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Patient's Name: |
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Sex (circle): |
Date of Birth: |
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Insurance ID #: |
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Shipping |
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Phone Number: |
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Address: |
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City: |
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State: |
Zip: |
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Alternate Phone Number: |
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Drug Allergies: |
None Known |
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Others: |
Health Conditions: |
High Blood Pres. |
Others: |
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Penicillin |
Cephalosporins |
Ampicillin |
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Diabetes |
Arthritis |
High Cholesterol |
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Sulfa |
Erythromycin |
Aspirin |
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Glaucoma |
Asthma |
Thyroid Disorder |
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Codeine |
Tetracycline |
Quinolones |
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Osteoporosis |
Cancer |
Heart Condition |
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Medication
& Strength:
Directions:
Qty
Refills: |
0 |
1 |
2 |
3 Other: |
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Brand Only: |
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YES |
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Medication |
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& Strength: |
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Directions: |
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Qty
Refills: |
0 |
1 |
2 |
3 Other: |
Brand Only: |
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YES |
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Medication
& Strength:
Directions:
Qty
Refills: |
0 |
1 |
2 |
3 Other: |
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Brand Only: |
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YES |
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Medication |
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& Strength: |
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Directions: |
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Qty
Refills: |
0 |
1 |
2 |
3 Other: |
Brand Only: |
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YES |
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Physician's
Name:
Street:
City:
Phone:
Signature:
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NPI: |
DEA: |
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State: |
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Zip: |
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Fax: |
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Date: |
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SIGN and Fax Back to:
Health care information is personal and sensitive information related to a person’s health care. If health care information is included with this fax, it is being faxed to you after appropriate authorization or under circumstances that do not require authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner.