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.
Diabetes management (DM) process
This document describes the process for providing diabetes disease management program services to members.
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.
Pre-service peer-to-peer requests
Find guidelines for requesting a peer-to-peer discussion.
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.
Utilization management program description
This document describes the program and how it works.
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.
Inter-rater reliability
This document covers how to do annual IRR training for prior authorization clinical staff.
Utilization decision criteria
Optum uses decision-making criteria that are objective, measurable and evidence based.
Care transition procedures
This document defines the process for discharging and safely transitioning Medicare Advantage patients from an inpatient facility.
Member satisfaction survey process
Learn the steps to evaluate members' satisfaction and complaints.
Appeal information request policy
This policy outlines the process for sending denial documents to the health plan or QIO for appeal consideration.
Complex case management (CCM) process
This document outlines the steps involved in identifying, educating and helping these patients.
Provider-member program awareness
This document specifies how providers and members are made aware of Optum Care–Kansas City case and disease management programs and services.
Gastroenterology referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Connecticut Prior Authorization Alert (OCN)
Reference for obtaining Prior Authorization lists and guidelines.
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.
Request for access to protected health information
"Complete and return this form if you would like to access and inspect the information Optum Specialty Pharmacy maintains and uses to make decisions about the services we provide you. "
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.
Request for record of non-routine disclosures of protected health information
Please complete and return the form to the requesting department.
Notice of privacy practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
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.
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.
Notice of privacy practices
Please complete and return the form to the requesting department.
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.
Claims provider manual
Our provider claims guide offers our network providers key information and support in submitting claims.
Direct admit to SNF form
Complete this form to initiate an admission to a skilled nursing facility (SNF).
Provider claim reconsideration request forms
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 - 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.
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
Optum Clinical Claims Review (CCR) Pre-Pay Review Quick Reference Guide
Learn about the CCR pre-pay review process
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.
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)
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.
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.
State of Arizona 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).
Partial Copay Waiver (PCW) Exception Prior Authorization Request Form
This is for CalPERS Plan only.
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).
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for New Mexico
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).
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
Massachusetts Hepatitis-C Medications Prior 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).
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).
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Oregon
Cancer Guidance Program Contract Termination
Provider notification of change in how authorization is obtained for chemo therapy drugs
Louisiana Prior Authorization Form
This form for Optum Rx (non-Medicare) and 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.
Submitting an electronic prior authorization (e-PA)
Prior authorization list (BCBS)
Get a list of codes for Optum Care-Arizona (BCBS Members).
SNF list
Providers directing community SNF admissions should reference the Arizona contracted SNF list.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Arizona, Colorado, Idaho, Kansas City, Nevada, and Utah
Optum Care management intake form
To refer to Optum Care management, submit a completed intake form.
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 for access to 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.