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Please note: All information below is required to process this request Mon Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific For real time submission 24/7 visit www.OptumRx.com and click Health Care

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5. If there are any specific formatting or document requirements, make sure to adhere to them.
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8. Sign and date the form, if necessary.
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Please note all information is a requirement to provide detailed and accurate information.

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All individuals or entities specified by the governing body are required to file please note all information.

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Please note all information must include relevant details such as financial data, contact information, and any other required information.