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OptumRx has partnered with CoverMyMeds to receive prior authorization requests saving you time and often delivering real-time determinations. Visit go. covermymeds. com/OptumRx to begin using this free service. Please note All information below is required to process this request. Mon-Fri 5am to 10pm Pacific / Sat 6am to 3pm Pacific Kerydin Prior Authorization Request Form Page 1 of 2 DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information required...
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To fill out the form for onychomycosis of toenails, follow these steps: 1. Start by collecting all the necessary documents and information related to your condition. 2. Begin with the patient information section. Enter your full name, date of birth, and contact details. 3. Next, provide details about your medical history, including any previous treatments or surgeries for onychomycosis. 4. Move on to the section where you describe your current symptoms. Mention any pain, discoloration, or deformities you have noticed in your toenails. 5. If you have any allergies or are taking any medications, make sure to disclose that information in the appropriate section. 6. Pay attention to the section where you need to describe the duration and progression of your condition. Include any relevant dates and details. 7. Complete the form by signing and dating it. 8. Double-check all the information provided before submitting the form.

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