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Forms and resources for health care professionals

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 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.

Gastroenterology referral form

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

Third party/donor referral form

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

Patient consent and assignment of benefits (AOB)

Please complete and return the form to the requesting department.

Multiple sclerosis referral form

Optum referral form for multiple sclerosis. Send us the form 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.

Hepatitis C referral form

Optum specialty referral form for hepatitis C patients. 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.

Request to amend protected health information (PHI)

Please complete and return the form to the requesting department.

Neuromuscular disorder referral form

Optum specialty referral form for neuromuscular disorders. 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.

Advance beneficiary notice of noncoverage (ABN)

Please complete and return the form to the requesting department.

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.

General referral form

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

Request to restrict use and disclosure of protected health information

Please complete and return the form to the requesting department.

Oncology referral form

Optum specialty referral form for oncology. 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.

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.

Request to amend 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.

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.

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.

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.

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.

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.

Rheumatology referral form

Optum specialty referral form for Rheumatology. 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.

Provider claim reconsideration request forms

Use these forms for the Optum Care Network–Utah.

Provider claim reconsideration request forms

Use these forms for the Washington market.

Claims provider manual

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

Provider claim reconsideration request form

Use these forms for the New Mexico market.

Prior authorization list

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

Provider claim reconsideration request forms

Use this form to challenge, appeal or request reconsideration of a claim.

Provider claim reconsideration request form

Use these forms for the Nevada market.

Provider claim reconsideration request form

Use these forms for the New York market.

Provider Claim Reconsideration Request Form

Use this form to challenge, appeal or request reconsideration of a claim.

Provider claim reconsideration request 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.

Provider claim reconsideration request form

Use these forms for the Oregon market.

Prior authorization list (UHC)

Get a list of codes for Optum Care-Arizona (UHC Members).

Prior authorization grid

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

Alpha-1 referral form

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

Provider claim reconsideration request form

Use these forms for the Kansas City 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.

Provider Claim Reconsideration Request Form

Challenge, appeal or request reconsideration of a claim.

Provider dispute resolution request

Complete this form to request a dispute resolution.

Prior authorization grid

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

Provider claim reconsideration request form

Use these forms for the South Carolina market.

Online prior authorization submissions

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

Provider claim reconsideration request forms

Use these forms for the Wisconsin market.

Prior authorization grid South Carolina

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

Prior authorization requirements for Optum Care Network–New Mexico

View the prior authorization process for New Mexico.

Benzodiazpines Prior Authorization Form

This is a Medicare form for benzodiazepines prior authorization requests.

Prior authorization grid

View a list of CPT codes requiring prior authorization for Idaho

Medicare Part D Prior Authorization for Hospice Form

Use this form for hospice enrollees.

Prior authorization grid

View a list of CPT codes requiring prior authorization for Utah

Prior Authorization Request Form

This is a Medicare form for general PA requests.

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

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

Opioids & Medication Limits Prior Authorization Request Form

Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.

Prescription Drug Reference Pricing Program

This form is for UFCW Plans only.

Delaware Prior Authorization Form

The form is for 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 Form UHC

This form is for UnitedHealthcare (non-Medicare).

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).

Florida Prior Authorization Form

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

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).

Massachusetts Chemotherapy and Supportive Care PA 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).

Illinois Prior Authorization Form

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

Member Pays Difference Exceptions PA Form

This form is for CalPERS Plan only.

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 Washington

Prior Authorization Request Form

Use this form for Emergient North Dakota plan only.

Massachusetts Hepatitis-C Medications Prior Authorization Form

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

Prior Authorization Request Form

Use this form for Emergient Vermont Plan only.

Healthcare Reform Copay Waiver Request Form

This is for OptumRx (non-Medicare).

State of California 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).

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).

Massachusetts Synagis 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).

Louisiana Prior Authorization Form

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

Rhode Island Prior Authorization Form

This form is for UnitedHealthcare (non-Medicare).

EDI Companion Guide

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

Provider claim reconsideration request form - APN

Challenge, appeal or request reconsideration of a claim.

Prior authorization list (BCBS)

Get a list of codes for Optum Care-Arizona (BCBS Members).

Provider claim reconsideration request form

Use these forms for the Ohio market.

SNF list

Providers directing community SNF admissions should reference the Arizona contracted SNF list.

Prior authorization requirements for Optum APN-Connecticut

View the prior authorization process for Connecticut.

Authorization to use and disclose protected health information

Please complete and return the form to the requesting department.

Request to restrict use and disclosure of protected health information

Please complete and return the form to the requesting department.

Optum-OR physician/provider change form

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

Prior authorization grid

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

Prior authorization grid

View a list of CPT codes requiring a prior authorization for New Jersey.

Prior authorization grid

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

Prior authorization grid

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

Prior authorization request form

Use this form to request prior authorization of necessary services in the Optum West markets. See the prior authorization grid for a list of this year's services.

Optum Care management intake form

To refer to Optum Care management, submit a completed intake form.

Provider claim reconsideration request form

Use this form to challenge, appeal or request reconsideration of a claim.

Provider claim reconsideration request form

Use this form to challenge, appeal or request reconsideration of a claim.

Provider claim reconsideration request form

Use this form to challenge, appeal or request reconsideration of a claim.

Provider claim reconsideration request form

Use this form to challenge, appeal or request reconsideration of a claim.

Managed Infertility Program Prior Authorization Form

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

Fertility Solutions Provider Prior Authorization Form

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