OPTUMRx 104-0006 2013 free printable template
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New Prescription Fax Order Form 1 Please fill out Section 1, then have your physician fill out Section 2 and FAX it to 1-800-491-7997. NOTE: THIS FAX IS VOID UNLESS RECEIVED DIRECTLY FROM YOUR PHYSICIAN
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How to fill out OPTUMRx 104-0006
How to fill out OPTUMRx 104-0006
01
Obtain the OPTUMRx 104-0006 form from the official website or your pharmacy.
02
Fill in your personal information in the designated fields, including your name, address, and contact information.
03
Provide your insurance information, including your policy number and group number.
04
Indicate the medications you are requesting by including the medication name, dosage, and quantity.
05
Include any relevant prescription information, such as the prescribing doctor's details.
06
Review the filled-out form for completeness and accuracy.
07
Sign and date the form where indicated.
08
Submit the completed form via mail, fax, or electronically as per the instructions provided.
Who needs OPTUMRx 104-0006?
01
Individuals who are enrolled in a prescription benefit plan through OPTUMRx.
02
Patients who need to request prior authorization for their medications.
03
Members who require specialty pharmacy services provided by OPTUMRx.
04
Those who are changing or updating their medication requests.
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What is OPTUMRx 104-0006?
OPTUMRx 104-0006 is a form used for reporting specific information related to pharmacy claims and services provided by OPTUMRx.
Who is required to file OPTUMRx 104-0006?
Organizations and individuals that provide pharmacy benefits and are part of the OPTUMRx network must file the OPTUMRx 104-0006 form.
How to fill out OPTUMRx 104-0006?
To fill out OPTUMRx 104-0006, ensure all required fields are completed accurately, including patient details, drug information, and claim specifics, following the instructions provided with the form.
What is the purpose of OPTUMRx 104-0006?
The purpose of OPTUMRx 104-0006 is to ensure accurate reporting and processing of pharmacy claims to maintain compliance and facilitate reimbursement for pharmacy services.
What information must be reported on OPTUMRx 104-0006?
Information that must be reported on OPTUMRx 104-0006 includes patient demographics, prescription details, pharmacy information, and any relevant billing codes.
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