Forms and resources for health care professionals
Neuromuscular disorder referral form
Optum specialty referral form for neuromuscular disorders. 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.
Dermatology referral form
Optum specialty referral form for Dermatology. Send us the form and we will take care of the rest.
State of California prior authorization form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Advance beneficiary notice of noncoverage (ABN)
Please complete and return the form to the requesting department.
Prior authorization grid
View a list of CPT codes requiring prior authorization for Kansas City.
Arizona radiation therapy prior authorization
Learn more about the prior authorization process.
Prior authorization request form
Use this form to request prior authorization of necessary services in Connecticut. See the prior authorization grid for a list of this year's services.
Fertility general referral form
Optum specialty fertility referral form. Send us the form and we will take care of the rest.
Advance beneficiary notice of noncoverage (ABN)
Please complete and return the form to the requesting department.
EDI Companion Guide
HIPAA Companion Guides describe Optum Rx specific technical details for EDI transactions.
Unbranded parenteral nutrition referral form
Unbranded parenteral nutrition infusion referral/enrollment form
Oregon Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Optum Provider Change Form
Please use this form to request demographic updates, remit address changes, or updates to your practice information.
UHC West of California delegated medical group auto-authorization form
This form for UnitedHealthcare (non-Medicare).
General referral form
General Optum specialty referral form. Send us the form and we will take care of the rest.
Massachusetts Synagis Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Gastroenterology referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Minnesota Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Oregon
Provider dispute resolution form - APN
Challenge, appeal or request reconsideration of a claim.
Opioid antagonist referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Osteoporosis referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Prior authorization requirements for Optum Care Network–New Mexico
View the prior authorization process for New Mexico.
Cancer Guidance Program Contract Termination
Provider notification of change in how authorization is obtained for chemo therapy drugs
Rheumatology referral form
Optum specialty referral form for Rheumatology. Send us the form and we will take care of the rest.
Louisiana Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Third party/donor referral form
Optum specialty referral form for donors and third party fertility patients.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Arizona, Colorado, Idaho, Kansas City, Nevada, and Utah
Prior authorization grid
View a list of CPT codes requiring a prior authorization for Indiana, Ohio and New York.
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.
Submitting an electronic prior authorization (e-PA)
Multiple sclerosis referral form
Optum specialty referral form for multiple sclerosis. 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.
Benzodiazpines Prior Authorization Form
This is a Medicare form for benzodiazepines prior authorization requests.
Opioids & Medication Limits Prior Authorization Request Form
Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.
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.
Optum Care ACE Smart Edits
Learn more about the Advanced Communication Engine and the edits currently in place.
Immunoglobulin referral form
Optum Infusion Pharmacy IVIG and SCIG referral/enrollment form. Send us the referral and we will take care of the rest.
Claims provider manual
Our provider claims guide offers our network providers key information and support in submitting claims.
State of Arizona prior authorization form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Texas Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Partial Copay Waiver (PCW) Exception Prior Authorization Request Form
This is for CalPERS Plan only.
Prior authorization request form
View the prior authorization request form for the Indiana, New York and Ohio markets.
Massachusetts Prior General Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Colorado Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Unbranded multiple sclerosis referral form - Infusion
Optum Infusion Pharmacy unbranded referral form for multiple sclerosis. Send us the form and we will take care of the rest.
Florida Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Arizona Chemotherapy Drug Prior Authorization
Learn more about the prior authorization process.
Prior authorization grid
View a list of CPT codes requiring prior authorization for Idaho
Direct admit to SNF form
Complete this form to initiate an admission to a skilled nursing facility (SNF).
Prior authorization grid
View a list of CPT codes requiring a prior authorization for Wisconsin.
Alpha-1 referral form
Optum Infusion Pharmacy referral/enrollment form for alpha-1 proteinase inhibitor therapy
Healthcare Reform Copay Waiver Request Form
This for is for UnitedHealthcare (non-Medicare).
New Mexico Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Medicare Part D Prior Authorization for Hospice Form
Use this form for hospice enrollees.
Home Health Care prior authorization intake request form
View the prior authorization request form for the Connecticut, Indiana, and Ohio market.
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.
Prior authorization request form
Use this form to request prior authorization of necessary services in Oregon. To view prior authorization requirements, refer to UHC Medicare Advantage Prior Auth Guidelines.
Hepatitis C referral form
Optum specialty referral form for hepatitis C patients. Send us the form and we will take care of the rest.
Optum Clinical Claims Review (CCR) Pre-Pay Review Quick Reference Guide
Learn about the CCR pre-pay review process
Unbranded IV anti-infectives referral form
Unbranded antibiotic infusion referral/enrollment form
Unbranded immunoglobulin referral form
Unbranded IVIG and SCIG infusion referral/enrollment form
Unbranded alpha-1 referral form
Unbranded referral/enrollment form for alpha-1 proteinase inhibitor therapy
Optum Care ACE quick reference guide
Get important details about the Advanced Communication System.
Massachusetts Chemotherapy and Supportive Care PA Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for New Mexico
Request to amend protected health information
Please complete and return the form to the requesting department.
Michigan Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization request form
Use this form to request prior authorization of necessary services in Washington. See the prior authorization grid for a list of this year's services.
Biologics infusion referral form
Complete and return this form to refer a patient for biologic infusion therapy with Optum Infusion Pharmacy.
Unbranded hemophilia and bleeding disorders referral form
Unbranded hemophilia referral/enrollment form
Illinois Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization request form
Use this form to request prior authorization of necessary services in New Mexico. See the prior authorization grid for a list of this year's services.
Online prior authorization submissions
View important benefits of submitting prior authorizations online using the prior authorization module (Curo)
Pulmonary arterial hypertension referral form
Optum specialty referral form for pulmonary arterial hypertension (PAH). Send us the form and we will take care of the rest.
Request for confidential communications at an alternative address
Please complete and return the form to the requesting department.
Optum-WA physician/provider change form
Please use this form to request demographic updates, remit address changes, or updates to your practice information.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Connecticut
Request to amend protected health information (PHI)
Please complete and return the form to the requesting department.
New Hampshire Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Indiana, Ohio, and New York
Multiple sclerosis referral form - Infusion
Optum Infusion Pharmacy referral form for multiple sclerosis. Send us the form and we will take care of the rest.
Provider dispute resolution forms
Use these forms when working with patients in Colorado.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Washington
Provider dispute resolution form - CT
Challenge, appeal or request reconsideration of a claim.
Provider dispute resolution form
Challenge, appeal or request reconsideration of a claim.
Washington Provider Manual
Our provider guide offers our network providers key information and support to provide effective care in the Washington market.
Osteoarthritis referral form
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.
Oncology REMS referral form
Optum specialty referral form for REMS oncology medications. Send us the form 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.
Massachusetts Hepatitis-C Medications Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Opioids & Medication Limits Prior Authorization Request Form-UnitedHealthcare Medicare only
Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.
Prior authorization grid South Carolina
View a list of CPT codes requiring a prior authorization for South Carolina.
Request for confidential Optum Infusion Pharmacy communications at an alternative address or by another means
Please complete and return the form to the requesting department.
Prior authorization list (BCBS)
Get a list of codes for Optum Care-Arizona (BCBS Members)
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