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Forms and resources for health care professionals (80)

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    Advance beneficiary notice of noncoverage (ABN)

    Please complete and return the form to the requesting department.

    Advance beneficiary notice of noncoverage (ABN)

    Please complete and return the form to the requesting department.

    Alpha-1 referral form

    Optum Infusion Pharmacy referral/enrollment form for alpha-1 proteinase inhibitor therapy

    Authorization to use and disclose protected health information

    Please complete and return the form to the requesting department.

    Biologics infusion referral form

    Complete and return this form to refer a patient for biologic infusion therapy with Optum Infusion Pharmacy.

    Claims provider manual

    Our provider claims guide offers our network providers key information and support in submitting claims.

    Dermatology referral form

    Optum specialty referral form for Dermatology. Send us the form and we will take care of the rest.

    Fertility general referral form

    Optum specialty fertility referral form. Send us the form and we will take care of the rest.

    Fertility Solutions Provider Prior Authorization Form

    UHC providers may use this form to submit for infertility/fertility prior authorization.

    Gastroenterology referral form

    Optum specialty referral form. Send us the form and we will take care of the rest.

    General referral form

    General Optum specialty referral form. Send us the form and we will take care of the rest.

    Hemophilia and bleeding disorders referral form

    Optum Infusion Pharmacy referral/enrollment form for hemophilia and bleeding disorders. Send us the referral and we will take care of the rest.

    Hepatitis C referral form

    Optum specialty referral form for hepatitis C patients. Send us the form and we will take care of the rest.

    Home parenteral nutrition referral form

    Optum Infusion Pharmacy referral/enrollment form for parenteral nutrition. Send us the referral and we will take care of the rest.

    Immune globulin therapy enrollment form

    Optum specialty referral/enrollment form for immune globulin. Send us the form and we will take care of the rest.

    Immunoglobulin Order Form - Infusion

    Optum Infusion Pharmacy IVIG and SCIG referral/enrollment form. Send us the referral and we will take care of the rest.

    IV anti-infectives referral form

    Optum Infusion Pharmacy referral/enrollment form for antibiotics. Send us the referral and we will take care of the rest.

    Managed Infertility Program Prior Authorization Form

    Oxford providers may use this form to submit for infertility/fertility prior authorization.

    Multiple sclerosis referral form

    Optum referral form for multiple sclerosis. Send us the form and we will take care of the rest.

    Neuromuscular disorder referral form

    Optum specialty referral form for neuromuscular disorders. Send us the form and we will take care of the rest.

    Neuromuscular disorder referral form – migraine, cervical dystonia, overactive bladder

    Optum specialty referral form. Send us the form and we will take care of the rest.

    Neuromuscular disorder referral form– achalasia, chronic anal fissure, fetrusor overactivity, spasticity, bleopharospasm

    Optum specialty referral form. Send us the form and we will take care of the rest.

    Oncology referral form

    Optum specialty referral form for oncology. Send us the form and we will take care of the rest.

    Oncology REMS referral form

    Optum specialty referral form for REMS oncology medications. Send us the form and we will take care of the rest.