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Get and Sign Optumrx Prior Authorization Appeal Form 2019-2021

(required) Provider Information (required) Member Name: Provider Name: Insurance ID#: NPI#: Date of Birth: Office Phone: Street Address: Office Fax: City: State: Zip: Phone: Specialty: Office Street Address: City: State: Zip: Medication Information (required) Medication Name: Strength:  Check if requesting brand  Check if request is for continuation of therapy Directions for Use: Dosage Form: Clinical Information (required) Select the diagnosis below:  Chronic...

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