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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 Professionals OptumRx M/S CA 106-0286 3515 Harbor Blvd. Costa Mesa CA 92626 Prior Authorization Request Form DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information required Provider Information required Member Name Provider Name Insurance ID NPI Date of...
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