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.
![Neuromuscular disorder referral form– achalasia, chronic anal fissure, fetrusor overactivity, spasti](/content/hub5/neuromuscular-disorder-enrollment-achalasia/_jcr_content/root/container/container/column_half_copy_cop/col1/o4_adaptiveimage.jpg)
This is an Optum prior authorization criteria specific form to prescribe Botox treatment for achalasia, chronic anal fissure, detrusor overactivity, spasticity, bleopharospasm from Optum Specialty Pharmacy.