Optumrx Prescription Fax Form PDF Details

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.

QuestionAnswer
Form NameOptumrx Prescription Fax Form
Form Length1 pages
Fillable?Yes
Fillable fields77
Avg. time to fill out15 min 43 sec
Other namesoptumrx appeal form pdf, 800 791 7658, fax number for optum rx, optumrx refill request

Form Preview Example

 

 

 

 

 

 

 

 

Quick-Fax

 

5510

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax: 1-800-491-7997

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician:

Please provide:

 

 

 

 

Customer Service Phone #: 1-800-562-6223

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Patient Information

 

 

 

Physician's Line: 1-800-791-7658

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Prescription Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

90 day supply is preferred

 

 

 

Note: Schedule II medications cannot be faxed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient's Name:

 

 

 

 

 

 

Sex (circle):

Date of Birth:

 

Insurance ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shipping

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

State:

Zip:

 

Alternate Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug Allergies:

None Known

 

 

Others:

Health Conditions:

High Blood Pres.

Others:

 

 

 

 

Penicillin

Cephalosporins

Ampicillin

 

 

 

Diabetes

Arthritis

High Cholesterol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sulfa

Erythromycin

Aspirin

 

 

 

Glaucoma

Asthma

Thyroid Disorder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Codeine

Tetracycline

Quinolones

 

 

 

Osteoporosis

Cancer

Heart Condition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication

& Strength:

Directions:

Qty

Refills:

0

1

2

3 Other:

Brand Only:

 

YES

 

 

 

 

 

 

 

 

 

 

 

Medication

 

 

 

 

 

 

& Strength:

 

 

 

 

 

Directions:

 

 

 

 

 

 

Qty

Refills:

0

1

2

3 Other:

Brand Only:

 

YES

 

 

Medication

& Strength:

Directions:

Qty

Refills:

0

1

2

3 Other:

Brand Only:

 

YES

 

 

 

 

 

 

 

 

 

 

 

Medication

 

 

 

 

 

 

& Strength:

 

 

 

 

 

Directions:

 

 

 

 

 

 

Qty

Refills:

0

1

2

3 Other:

Brand Only:

 

YES

 

 

Physician's

Name:

Street:

City:

Phone:

Signature:

 

NPI:

DEA:

 

 

State:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGN and Fax Back to: 1-800-491-7997

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. Re-disclosure without the additional consent of such person whose health care information is attached or as permitted by law is strictly prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law.

How to Edit Optumrx Prescription Fax Form Online for Free

We have applied the efforts of our best computer programmers to create the PDF editor you are going to take advantage of. The software will enable you to fill out the fax number for optumrx form without trouble and don’t waste time. Everything you need to do is keep up with these particular quick directions.

Step 1: Pick the button "Get Form Here".

Step 2: At the moment, you can modify the fax number for optumrx. Our multifunctional toolbar allows you to insert, remove, adjust, highlight, as well as undertake other commands to the content material and fields inside the file.

To complete the fax number for optumrx PDF, provide the content for each of the parts:

writing optumrx fax number part 1

Enter the appropriate particulars in the box Refills, Other, Refills, Other, BrandOnly, YES, BrandOnly, YES, MedicationStrength, Directions, Qty, MedicationStrength, Directions, Qty, and Refills.

Completing optumrx fax number stage 2

Step 3: Press "Done". You can now export your PDF document.

Step 4: Ensure you remain away from upcoming issues by making at least 2 duplicates of your document.

Watch Optumrx Prescription Fax Form Video Instruction

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