Forms and resources for health care professionals (117)
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Advance beneficiary notice of noncoverage (ABN)
Please complete and return the form to the requesting department.
Advance beneficiary notice of noncoverage (ABN)
Please complete and return the form to the requesting department.
Alpha-1 referral form
Optum Infusion Pharmacy referral/enrollment form for alpha-1 proteinase inhibitor therapy
Authorization to use and disclose protected health information
Please complete and return the form to the requesting department.
Benzodiazpines Prior Authorization Form
This is a Medicare form for benzodiazepines prior authorization requests.
Biologics infusion referral form
Complete and return this form to refer a patient for biologic infusion therapy with Optum Infusion Pharmacy.
Claims provider manual
Our provider claims guide offers our network providers key information and support in submitting claims.
Colorado Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Delaware Prior Authorization Form
The form is for UnitedHealthcare (non-Medicare).
Dermatology referral form
Optum specialty referral form for Dermatology. Send us the form and we will take care of the rest.
EDI Companion Guide
HIPAA Companion Guides describe Optum Rx specific technical details for EDI transactions.
Fertility general referral form
Optum specialty fertility referral form. Send us the form and we will take care of the rest.
Fertility Solutions Provider Prior Authorization Form
UHC providers may use this form to submit for infertility/fertility prior authorization.
Florida 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.
General referral form
General Optum specialty referral form. Send us the form and we will take care of the rest.
Healthcare Reform Copay Waiver Request Form
This for is for UnitedHealthcare (non-Medicare).
Healthcare Reform Copay Waiver Request Form
This is for OptumRx (non-Medicare).
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.
Hepatitis C referral form
Optum specialty referral form for hepatitis C patients. 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.
Illinois Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
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 Order Form - Infusion
Optum Infusion Pharmacy IVIG and SCIG referral/enrollment form. Send us the referral and we will take care of the rest.