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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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1. Ensure you have all the required information before starting to fill out the form
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3. Begin by providing your personal details such as name, address, and contact information
4. If applicable, include any identification numbers required
5. Fill in the necessary information in the designated fields or boxes
6. Double-check all the entered information for accuracy and completeness
7. If there are any additional sections or pages, make sure to complete them as well
8. Review the filled-out form one last time before submitting
9. Submit the form through the specified method, such as mailing it or submitting it online
10. Keep a copy of the filled-out form for your records

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1. Anyone who is required or requested to provide specific information, as outlined in the form
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6. Businesses or individuals applying for loans or financial aid
7. Insurance applicants or policyholders
8. People involved in legal or court proceedings
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10. Individuals seeking to update or change their personal information

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Please note all information refers to the required details that need to be reported or documented.

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The information to be reported on please note all information can vary depending on the specific requirements, but generally includes relevant data or details.