O4 Hubs

Forms and resources for health care professionals

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.

Unbranded hemophilia and bleeding disorders referral form

Unbranded hemophilia referral/enrollment form

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.

Hub referral card

How to refer your patients with multiple sclerosis.

Third party/donor referral form

Optum specialty referral form for donors and third party fertility patients.

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 referral form

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

Synagis referral form

Optum Specialty RSV referral form for Synagis.

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.

Hepatitis C referral form

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

Unbranded IV anti-infectives referral form

Unbranded antibiotic infusion referral/enrollment form

Unbranded immunoglobulin referral form

Unbranded IVIG and SCIG infusion referral/enrollment form

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.

Unbranded biologics infusion referral form

Unbranded infusion referral/enrollment form

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.

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.

Fertility general referral form

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

Unbranded parenteral nutrition referral form

Unbranded parenteral nutrition infusion referral/enrollment form

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.

Evidence in action

Get a closer look at how evidence is advancing life sciences.

Arizona Chemotherapy Drug Prior Authorization

Learn more about the prior authorization process.

Provider lookup tool

Find doctors in Arizona.

Provider dispute resolution form - CT

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.

Washington quick reference guide

Get important details for the Washington market.

Provider dispute resolution forms

Use these forms for the Optum Care Network–Utah.

Provider dispute resolution forms

Use these forms for the Washington market.

Provider dispute resolution forms

Use these forms for the New Mexico market.

Direct admit to SNF form

Complete this form to initiate an admission to a skilled nursing facility (SNF).

Primary care provider referral form

View the Optum Care–Utah provider referral form.

Prior authorization list

Get a list of codes for the Optum Care–Colorado.

Specialist referral form

Get a referral form for specialists in Arizona.

Provider dispute resolution forms

Use these forms for the Indiana market.

Provider quick reference guide

Get important details for the Ohio market.

Provider dispute resolution forms

Use these forms for the Nevada market.

Provider dispute resolution forms

Use these forms for the Ohio market.

Provider dispute resolution forms

Use these forms for the New York market.

Provider dispute resolution forms

Use these forms when working with patients in Colorado.

Provider dispute resolution form

Challenge, appeal or request reconsideration of a claim.

Provider dispute resolution request

Complete this form to request a dispute resolution.

Provider dispute resolution forms

Use these forms for the Oregon market.

Prior authorization list

Get a list of codes for Optum Care–Arizona.

Alpha-1 referral form

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

Optum Clinical Claims Review (CCR) Pre-Pay Review Quick Reference Guide

Learn about the CCR pre-pay review process

Unbranded alpha-1 referral form

Unbranded referral/enrollment form for alpha-1 proteinase inhibitor therapy

Provider dispute resolution form

Use these forms for the Kansas City market.

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.

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.

Prior authorization request form

View the prior authorization request form for the Indiana, New York and Ohio markets.

Provider dispute resolution form - APN

Challenge, appeal or request reconsideration of a claim.

Submitting an electronic prior authorization (e-PA)

Oncology referral form

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

Home Health Care prior authorization intake request form

View the prior authorization request form for the Connecticut, Indiana, and Ohio market.

Optum-WA physician/provider change form

Please use this form to request demographic updates, remit address changes, or updates to your practice information.

EDI Companion Guide

HIPAA Companion Guides describe Optum Rx specific technical details for EDI transactions.

Multiple sclerosis referral form

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

Medicare Part D Prior Authorization for Hospice Form

Use this form for hospice enrollees.

Optum Provider Change Form

Please use this form to request demographic updates, remit address changes, or updates to your practice information.

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.

Prior Authorization Request Form

Use this form for Emergient North Dakota plan only.

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 Request Form

Use this form for Emergient Vermont Plan only.

Healthcare Reform Copay Waiver Request Form

This is for OptumRx (non-Medicare).

Member Pays Difference Exceptions PA Form

This form is for CalPERS Plan only.

Prior Authorization Request Form

This is a Medicare form for general PA requests.

Prescription Drug Reference Pricing Program

This form is for UFCW Plans only.

Healthcare Reform Copay Waiver Request Form

This for is for UnitedHealthcare (non-Medicare).

Delaware Prior Authorization Form

The form is for UnitedHealthcare (non-Medicare).

UHC West of California delegated medical group auto-authorization form

This form for UnitedHealthcare (non-Medicare).

Rhode Island Prior Authorization Form

This form is for UnitedHealthcare (non-Medicare).

Partial Copay Waiver (PCW) Exception Prior Authorization Request Form

This is for CalPERS Plan only.

Prior Authorization Form UHC

This form is for UnitedHealthcare (non-Medicare).

Massachusetts Chemotherapy and Supportive Care PA Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Massachusetts Hepatitis-C Medications Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Louisiana Prior 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).

Illinois Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

State of Arizona prior authorization form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Florida Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Massachusetts Prior General Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

State of California prior authorization form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

New Hampshire Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

New Mexico Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Minnesota Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Michigan Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Oregon Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Massachusetts Synagis 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).

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for New Mexico

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Connecticut

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Indiana, Ohio, and New York

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Washington

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Oregon

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Arizona, Colorado, Idaho, Kansas City, Nevada, and Utah

Osteoarthritis referral form

Optum specialty referral form. Send us the form 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.

General referral form

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

Gastroenterology 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.

Rheumatology referral form

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

Biologics infusion referral form

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

Cancer Guidance Program Contract Termination

Provider notification of change in how authorization is obtained for chemo therapy drugs

Optum-WA/OR care management referral form

This is a form for fax submissions.

Opioid antagonist referral form

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

New hope for neurological conditions

Learn how a holistic model enhances multiple sclerosis care.

Online prior authorization submissions

View important benefits of submitting prior authorizations online using the prior authorization module (Curo)

Prior authorization grid South Carolina

View a list of CPT codes requiring a prior authorization for South Carolina.

Prior authorization grid

View a list of CPT codes requiring a prior authorization for Wisconsin.

Claims provider quick reference guide

Get important details for provider claims.

Provider dispute resolution forms

Use these forms for the South Carolina market.

Provider dispute resolution forms

Use these forms for the Wisconsin market.

Optum Care ACE Smart Edits

Learn more about the Advanced Communication Engine and the edits currently in place.

Optum Care ACE quick reference guide

Get important details about the Advanced Communication System.

Claims provider manual

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

Prior authorization grid

View a list of CPT codes requiring prior authorization for Kansas City

Prior authorization grid

View a list of CPT codes requiring prior authorization for Idaho

Prior authorization grid

View a list of CPT codes requiring prior authorization for Utah

Prior authorization grid

View a list of CPT codes requiring a prior authorization for Indiana, Ohio and New York.