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Specialty pharmacy referral and enrollment forms

Find forms to enroll or prescribe treatment from Optum Specialty Pharmacy. 

Download the referral form

Select the right form for your patients' needs from the list below.

Fill out the form

Provide all of the necessary patient and provider information.

Submit to Optum

Use the contact information on the form to submit it to Optum Specialty Pharmacy.

Forms

Download dermatology referral form 

Download fertility referral form

Download third-party/donor fertility referral form

Download gastroenterology referral form

Download general referral form

Download Hepatitis C referral form

Download immune globulin therapy referral form

Download multiple sclerosis referral form

Download neuromuscular disorder referral form
 

This is an Optum prior authorization criteria specific form to prescribe Botox treatment for migraines, cervical dystonia and overactive bladder:

Download neuromuscular disorder referral form
 

This is an Optum prior authorization criteria specific form to prescribe Botox treatment for achalasia, chronic anal fissure, detrusor overactivity, spasticity, bleopharospasm: 

Download neuromuscular disorder referral form

Download oncology referral form

Complete and return this form to enroll in Revlimid, Pomalyst or Thalomid treatment:

Download oncology REMS referral form 

Download opioid antagonist referral form

Download osteoporosis referral form

Download pulmonary arterial hypertension referral form 

Download rheumatology referral form

This is an Optum prior authorization criteria specific form to enroll or prescribe RSV and Synagis treatment: 

Download Synagis referral form

If you are looking to prescribe a medication that is injected or infused, please visit our Optum Infusion Pharmacy referral form page