Forms & Resources for Health Care Professionals

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data-asset="/content/dam/internal-resources/images/two-women-health-care-executives.jpg" data-asset-id="412b1681-0c63-4ee0-bf15-a4629a5260b7" id="image-b3556cb293" class="cmp-image" itemscope itemtype="http://schema.org/ImageObject"> <img src="/en/business/_jcr_content/root/o5_header_container/o5-mega-nav/navItems/item0/col4/image.coreimg.jpeg/1722973344912/two-women-health-care-executives.jpeg" class="cmp-image__image" itemprop="contentUrl" data-cmp-hook-image="image" alt/> </div> </div> <div class="dmp-type__body-2 o5-mega-nav-card__description"> <p><span class="o5-text__body-3-bold"><a href="https://www.optum.com/en/business/insights/page.hub5.2024-healthcare-trends-report.html">2024 Annual Health Care Trends Report</a></span></p> <p><span class="o5-text__body-3">Get expert analysis for C-suite health care leaders on the forces driving change.</span></p> </div> <div class="o5-mega-nav-card__action"> <a class="o5-mega-nav-card__action-link dmp-link-std--sm" href="https://www.optum.com/en/business/insights.html">View all Insights</a> </div> </div> </div> </div> </div> <div id="item1" class="o5-mega-nav-group--item o5-mega-nav-container dmp-container " qa_handles="o5-mega-nav-container"> <div class="o5-mega-nav__row dmp-row" role="navigation" aria-label="MegaNav"> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> <div class="o5-mega-nav-menu-items"> <div class="o5-mega-nav-menu-items--eyebrow">Care and health benefits</div> <ul class="o5-mega-nav-menu-items--list"> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/business/health-plans/behavioral-health.html"> Behavioral health </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/providers/health-systems/patient-access-engagement.html"> Patient access </a> </li> <li 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href="https://www.optum.com/en/business/employers/pharmacy-care-services.html"> Pharmacy benefits management </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/providers/pharmacy/infusion-pharmacy.html"> Infusion pharmacy </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/providers/pharmacy/home-delivery.html"> Home delivery </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/providers/pharmacy/specialty-pharmacy.html"> Specialty pharmacy </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.genoahealthcare.com/for-centers-facilities/"> Genoa Healthcare </a> </li> </ul> </div> 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href="https://www.optum.com/en/business/federal-government/health-policy.html"> Health policy consulting </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/business/health-plans/data-analytics/consulting.html"> Analytics consulting </a> </li> </ul> <div class="o5-mega-nav-menu-items-action"> <a class="dmp-btn dmp-btn--md dmp-btn--2 o5-mega-nav-menu-items-action--button" href="https://www.optum.com/en/library/health-finances.html">Explore your options</a> </div> </div> </div> </div> </div> <div id="item2" class="o5-mega-nav-group--item o5-mega-nav-container dmp-container " qa_handles="o5-mega-nav-container"> <div class="o5-mega-nav__row dmp-row" role="navigation" aria-label="MegaNav"> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> <div class="o5-mega-nav-card "> <div class="o5-mega-nav-card__image"> </div> <div class="o5-mega-nav-card__title">Insights</div> <div class="dmp-type__body-2 o5-mega-nav-card__description"> <p>Browse insights on making the health system work better for all</p> </div> </div> </div> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> <div class="o5-mega-nav-menu-items"> <div class="o5-mega-nav-menu-items--eyebrow">Topics</div> <ul class="o5-mega-nav-menu-items--list"> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/advisory-services.html"> Advisory services </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/financial-services.html"> Financial solutions </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/health-care-delivery.html"> Health care delivery </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/mental-health.html"> Mental health </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/pharmacy-care-services.html"> Pharmacy care services </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/population-health-management.html"> Population health management </a> </li> </ul> </div> </div> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> <div class="o5-mega-nav-menu-items"> <div class="o5-mega-nav-menu-items--eyebrow">In the spotlight</div> <ul class="o5-mega-nav-menu-items--list"> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/c-suite.html"> C-suite insights </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/about-us/social-responsibility/health-equity.html"> Health equity </a> </li> <li class="o5-mega-nav-menu-items--list-item"> <a class="dmp-link-std o5-mega-nav-menu-items--list-item-link" href="https://www.optum.com/en/business/insights/c-suite/page.hub.subscribe-newsletters.html"> Subscribe to healthcare newsletters </a> </li> </ul> </div> </div> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> <div class="o5-mega-nav-card o5-mega-nav-card--gray-background"> <div class="o5-mega-nav-card__image"> <div data-cmp-is="image" data-cmp-lazythreshold="0" data-cmp-src="/en/business/_jcr_content/root/o5_header_container/o5-mega-nav/navItems/item2/col4/image.coreimg{.width}.jpeg/1724423056938/insights-teaser-image.jpeg" data-asset="/content/dam/internal-resources/images/insights-teaser-image.jpg" data-asset-id="11573123-fa24-4dc9-8d36-6c5a20665e4c" id="image-6e1655ffb1" class="cmp-image" itemscope itemtype="http://schema.org/ImageObject"> <img src="/en/business/_jcr_content/root/o5_header_container/o5-mega-nav/navItems/item2/col4/image.coreimg.jpeg/1724423056938/insights-teaser-image.jpeg" class="cmp-image__image" itemprop="contentUrl" data-cmp-hook-image="image" alt/> </div> </div> <div class="dmp-type__body-2 o5-mega-nav-card__description"> <p><span class="o5-text__body-3-bold"><a href="https://www.optum.com/en/business/insights/page.hub.at-home-health-screenings.html">Making health screenings more convenient</a></span></p> <p><span class="o5-text__body-3">The pandemic has changed how people get care. At-home kits meet people where they live.</span></p> </div> <div class="o5-mega-nav-card__action"> <a class="o5-mega-nav-card__action-link dmp-link-std--sm" href="https://www.optum.com/en/business/insights.html">View all insights</a> </div> </div> </div> </div> </div> <div id="item3" class="o5-mega-nav-group--item o5-mega-nav-container dmp-container " qa_handles="o5-mega-nav-container"> <div class="o5-mega-nav__row dmp-row" role="navigation" aria-label="MegaNav"> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> </div> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> </div> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> </div> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> </div> </div> </div> <div id="item4" class="o5-mega-nav-group--item o5-mega-nav-container dmp-container " qa_handles="o5-mega-nav-container"> <div class="o5-mega-nav__row dmp-row" role="navigation" aria-label="MegaNav"> <div class="o5-mega-nav__col dmp-col-12 dmp-col-xl-3"> </div> <div 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id="container-7f47e3b8e5" class="cmp-container"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="o5-hubs aem-GridColumn aem-GridColumn--default--12"> <div id="o5-hubs-region" class="o5-hubs dmp-margin__top-32 dmp-container" data-qahandle="o5-hubs" qa_handles="o5-hubs-container" data-aem-module="o5-hubs" data-optum-cmp="o5-hubs" data-aem-authoring="/content/optum5/en/business/hcp-resources/jcr:content/root/container/container/o4_hubs.model.json"> <div data-optum-library-cmp="o5-hubs-header-region"> <div class="dmp-util-assist__text"> <h2>Forms and resources for health care professionals</h2> </div> </div> <div data-optum-library-cmp="o5-results"> <div class="dmp-util-assist__text"> <div> <h3>Optum-WA physician/provider change form</h3> <div>Please use this form to request demographic updates, remit address changes, or updates to your practice information.</div> <div><a href="/en/business/hcp-resources/page.hub5.optum-wa-provider-change-form.html">Learn more</a></div> </div> <div> <h3>Diabetes management (DM) process </h3> <div>This document describes the process for providing diabetes disease management program services to members.</div> <div><a href="/en/business/hcp-resources/page.hub5.diabetes-management-process-kansas-city.html">Learn more</a></div> </div> <div> <h3>Prior authorization request form</h3> <div>Use this form to request prior authorization of necessary services in Oregon. To view prior authorization requirements, refer to UHC Medicare Advantage Prior Auth Guidelines.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-oregon.html">Learn more</a></div> </div> <div> <h3>Pre-service peer-to-peer requests</h3> <div>Find guidelines for requesting a peer-to-peer discussion.</div> <div><a href="/en/business/hcp-resources/page.hub5.peer-to-peer-requests-kansas-city.html">Learn more</a></div> </div> <div> <h3>Prior authorization request form</h3> <div>Use this form to request prior authorization of necessary services in Washington. See the prior authorization grid for a list of this year's services.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-washington.html">Learn more</a></div> </div> <div> <h3>Utilization management program description</h3> <div>This document describes the program and how it works. </div> <div><a href="/en/business/hcp-resources/page.hub5.utilization-management-program-kansas-city.html">Learn more</a></div> </div> <div> <h3>Prior authorization request form</h3> <div>Use this form to request prior authorization of necessary services in New Mexico. See the prior authorization grid for a list of this year's services.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-new-mexico.html">Learn more</a></div> </div> <div> <h3>Inter-rater reliability</h3> <div>This document covers how to do annual IRR training for prior authorization clinical staff.</div> <div><a href="/en/business/hcp-resources/page.hub5.inter-rater-reliability-kansas-city.html">Learn more</a></div> </div> <div> <h3>Out-of-network determinations</h3> <div>Find instructions on how to review these requests.</div> <div><a href="/en/business/hcp-resources/page.hub5.out-of-network-determinations-kansas-city.html">Learn more</a></div> </div> <div> <h3>Utilization decision criteria</h3> <div>Optum uses decision-making criteria that are objective, measurable and evidence based.</div> <div><a href="/en/business/hcp-resources/page.hub5.utilization-decision-criteria-kansas-city.html">Learn more</a></div> </div> <div> <h3>Care transition procedures</h3> <div>This document defines the process for discharging and safely transitioning Medicare Advantage patients from an inpatient facility. </div> <div><a href="/en/business/hcp-resources/page.hub5.care-transition-procedures-kansas-city.html">Learn more</a></div> </div> <div> <h3>Quality of care grievance process</h3> <div>Learn how to report concerns about quality of care.</div> <div><a href="/en/business/hcp-resources/page.hub5.quality-of-care-grievance-process-kansas-city.html">Learn more</a></div> </div> <div> <h3>Subdelegation and vendor oversight</h3> <div>This document outlines the review process. </div> <div><a href="/en/business/hcp-resources/page.hub5.subdelegation-vendor-oversight-kansas-city.html">Learn more</a></div> </div> <div> <h3>Short-term case management (STCM) process</h3> <div>This document outlines STCM services. </div> <div><a href="/en/business/hcp-resources/page.hub5.short-term-case-management-kansas-city.html">Learn more</a></div> </div> <div> <h3>Member satisfaction survey process</h3> <div>Learn the steps to evaluate members' satisfaction and complaints.</div> <div><a href="/en/business/hcp-resources/page.hub5.member-satisfaction-survey-process-kansas-city.html">Learn more</a></div> </div> <div> <h3>Appeal information request policy</h3> <div>This policy outlines the process for sending denial documents to the health plan or QIO for appeal consideration. </div> <div><a href="/en/business/hcp-resources/page.hub5.appeal-information-request-policy-kansas-city.html">Learn more</a></div> </div> <div> <h3>Complex case management (CCM) process</h3> <div>This document outlines the steps involved in identifying, educating and helping these patients. </div> <div><a href="/en/business/hcp-resources/page.hub5.complex-case-management-process-kansas-city.html">Learn more</a></div> </div> <div> <h3>Utilization review procedure</h3> <div>This document identifies benchmarks for patient care.</div> <div><a href="/en/business/hcp-resources/page.hub5.utilization-review-procedure-kansas-city.html">Learn more</a></div> </div> <div> <h3>Provider-member program awareness</h3> <div>This document specifies how providers and members are made aware of Optum Care–Kansas City case and disease management programs and services.</div> <div><a href="/en/business/hcp-resources/page.hub5.program-awareness-kansas-city.html">Learn more</a></div> </div> <div> <h3>Gastroenterology referral form</h3> <div>Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.gastroenterology-referral-form.html">Learn more</a></div> </div> <div> <h3>Connecticut Prior Authorization Alert (OCN)</h3> <div>Reference for obtaining Prior Authorization lists and guidelines.</div> <div><a href="/en/business/hcp-resources/page.hub5.connecticut-ocn-prior-authorization-alert.html">Learn more</a></div> </div> <div> <h3>Third party/donor referral form</h3> <div>Optum specialty referral form for donors and third party fertility patients. </div> <div><a href="/en/business/hcp-resources/page.hub5.third-party-donor-referral.html">Learn more</a></div> </div> <div> <h3>Patient consent and assignment of benefits (AOB)</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.patient-consent-benefits-assignment.html">Learn more</a></div> </div> <div> <h3>Multiple sclerosis referral form</h3> <div>Optum referral form for multiple sclerosis. Send us the form and we will take care of the rest.</div> <div><a href="/en/business/hcp-resources/page.hub5.multiple-sclerosis-medication.html">Learn more</a></div> </div> <div> <h3>Immune globulin therapy enrollment form</h3> <div>Optum specialty referral/enrollment form for immune globulin. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.immune-globulin-therapy-enrollment.html">Learn more</a></div> </div> <div> <h3>Request for access to protected health information</h3> <div>"Complete and return this form if you would like to access and inspect the information Optum Specialty Pharmacy maintains and uses to make decisions about the services we provide you. "</div> <div><a href="/en/business/hcp-resources/page.hub5.phi-access-specialty-pharmacy.html">Learn more</a></div> </div> <div> <h3>Hepatitis C referral form</h3> <div>Optum specialty referral form for hepatitis C patients. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.hepatitis-c-enrollment.html">Learn more</a></div> </div> <div> <h3>Request for confidential communications at an alternative address</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.confidential-communications-specialty-pharmacy.html">Learn more</a></div> </div> <div> <h3>Request to amend protected health information (PHI)</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.amend-phi-request-specialty-pharmacy.html">Learn more</a></div> </div> <div> <h3>Request for record of non-routine disclosures of protected health information</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.non-routine-phi-disclosures-specialty-pharmacy.html">Learn more</a></div> </div> <div> <h3>Notice of privacy practices</h3> <div>This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.</div> <div><a href="/en/business/hcp-resources/page.hub5.privacy-practices-specialty-pharmacy.html">Learn more</a></div> </div> <div> <h3>Neuromuscular disorder referral form</h3> <div>Optum specialty referral form for neuromuscular disorders. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.neuromuscular-therapy-enrollment.html">Learn more</a></div> </div> <div> <h3>Dermatology referral form </h3> <div>Optum specialty referral form for Dermatology. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.dermatology-enrollment.html">Learn more</a></div> </div> <div> <h3>Advance beneficiary notice of noncoverage (ABN)</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.advance-beneficiary-noncoverage.html">Learn more</a></div> </div> <div> <h3>Fertility general referral form</h3> <div>Optum specialty fertility referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.infertility-enrollment.html">Learn more</a></div> </div> <div> <h3>Advance beneficiary notice of noncoverage (ABN)</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.advance-beneficiary-noncoverage-spanish.html">Learn more</a></div> </div> <div> <h3>General referral form</h3> <div>General Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.treatment-enrollment.html">Learn more</a></div> </div> <div> <h3>Request to restrict use and disclosure of protected health information</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.phi-restrict-use-specialty-pharmacy.html">Learn more</a></div> </div> <div> <h3>Oncology referral form</h3> <div>Optum specialty referral form for oncology. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.oncology-enrollment.html">Learn more</a></div> </div> <div> <h3>Immunoglobulin Order Form - Infusion</h3> <div>Optum Infusion Pharmacy IVIG and SCIG referral/enrollment form. Send us the referral and we will take care of the rest.</div> <div><a href="/en/business/hcp-resources/page.hub5.general-immunoglobulin-referral-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Synagis referral form</h3> <div>Optum Specialty RSV referral form for Synagis.</div> <div><a href="/en/business/hcp-resources/page.hub5.rsv-prior-authorization-specific-enrollment.html">Learn more</a></div> </div> <div> <h3>Neuromuscular disorder referral form – migraine, cervical dystonia, overactive bladder</h3> <div>Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.neuromuscular-disorder-enrollment-migraine.html">Learn more</a></div> </div> <div> <h3>Request to amend protected health information</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.amend-phi-request-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Biologics infusion referral form</h3> <div>Complete and return this form to refer a patient for biologic infusion therapy with Optum Infusion Pharmacy.</div> <div><a href="/en/business/hcp-resources/page.hub5.biologics-referral-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Pulmonary arterial hypertension referral form</h3> <div>Optum specialty referral form for pulmonary arterial hypertension (PAH). Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.pulmonary-arterial-hypertension-enrollment.html">Learn more</a></div> </div> <div> <h3>Osteoarthritis referral form </h3> <div>Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.osteoarthritis-enrollment.html">Learn more</a></div> </div> <div> <h3>Notice of privacy practices</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.privacy-practices-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Hemophilia and bleeding disorders referral form</h3> <div>Optum Infusion Pharmacy referral/enrollment form for hemophilia and bleeding disorders. Send us the referral and we will take care of the rest.</div> <div><a href="/en/business/hcp-resources/page.hub5.hemophilia-bleeding-disorders-referral.html">Learn more</a></div> </div> <div> <h3>Oncology REMS referral form</h3> <div>Optum specialty referral form for REMS oncology medications. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.revlimid-pomalyst-thalomid-enrollment.html">Learn more</a></div> </div> <div> <h3>IV anti-infectives referral form</h3> <div>Optum Infusion Pharmacy referral/enrollment form for antibiotics. Send us the referral and we will take care of the rest.</div> <div><a href="/en/business/hcp-resources/page.hub5.iv-anti-infective-referral-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Request for confidential Optum Infusion Pharmacy communications at an alternative address or by another means</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.confidential-communications-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Home parenteral nutrition referral form</h3> <div>Optum Infusion Pharmacy referral/enrollment form for parenteral nutrition. Send us the referral and we will take care of the rest.</div> <div><a href="/en/business/hcp-resources/page.hub5.home-parenteral-nutrition-referral-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Opioid antagonist referral form</h3> <div>Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.sublocade-enrollment.html">Learn more</a></div> </div> <div> <h3>Osteoporosis referral form </h3> <div>Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.osteoporosis-enrollment.html">Learn more</a></div> </div> <div> <h3>Rheumatology referral form</h3> <div>Optum specialty referral form for Rheumatology. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.rheumatology-enrollment.html">Learn more</a></div> </div> <div> <h3>Neuromuscular disorder referral form– achalasia, chronic anal fissure, fetrusor overactivity, spasticity, bleopharospasm</h3> <div>Optum specialty referral form. Send us the form and we will take care of the rest. </div> <div><a href="/en/business/hcp-resources/page.hub5.neuromuscular-disorder-enrollment-achalasia.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request forms</h3> <div>Use these forms for the Optum Care Network–Utah. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-utah.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request forms</h3> <div>Use these forms for the Washington market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-washington.html">Learn more</a></div> </div> <div> <h3>Claims provider manual</h3> <div>Our provider claims guide offers our network providers key information and support in submitting claims.</div> <div><a href="/en/business/hcp-resources/page.hub5.claims-provider-manual.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the New Mexico market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-new-mexico.html">Learn more</a></div> </div> <div> <h3>Direct admit to SNF form</h3> <div>Complete this form to initiate an admission to a skilled nursing facility (SNF). </div> <div><a href="/en/business/hcp-resources/page.hub5.direct-admit-snf-form-arizona.html">Learn more</a></div> </div> <div> <h3>Provider lookup tool </h3> <div>Find doctors in Arizona.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-lookup.html">Learn more</a></div> </div> <div> <h3>Prior authorization list</h3> <div>Get a list of codes for the Optum Care–Colorado. </div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-list-colorado.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request forms</h3> <div>Use this form to challenge, appeal or request reconsideration of a claim. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-indiana.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the Nevada market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-nevada.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the New York market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-new-york.html">Learn more</a></div> </div> <div> <h3>Provider Claim Reconsideration Request Form</h3> <div>Use this form to challenge, appeal or request reconsideration of a claim. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-colorado.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form - CT</h3> <div>Challenge, appeal or request reconsideration of a claim. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-connecticut.html">Learn more</a></div> </div> <div> <h3>Washington Provider Manual</h3> <div>Our provider guide offers our network providers key information and support to provide effective care in the Washington market.</div> <div><a href="/en/business/hcp-resources/page.hub5.medicaid-provider-manual-washington.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the Oregon market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-oregon.html">Learn more</a></div> </div> <div> <h3>Prior authorization list (UHC)</h3> <div>Get a list of codes for Optum Care-Arizona (UHC Members).</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-list-arizona.html">Learn more</a></div> </div> <div> <h3>Prior authorization grid</h3> <div>View a list of CPT codes requiring a prior authorization for Indiana, Ohio and New York.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-grid-in-ny-oh.html">Learn more</a></div> </div> <div> <h3>Evidence in action</h3> <div>Get a closer look at how evidence is advancing life sciences.</div> <div><a href="/en/business/hcp-resources/page.hub5.life-sciences-newsletter-subscribe.html">Learn more</a></div> </div> <div> <h3>Alpha-1 referral form</h3> <div>Optum Infusion Pharmacy referral/enrollment form for alpha-1 proteinase inhibitor therapy</div> <div><a href="/en/business/hcp-resources/page.hub5.alpha-1-referral.html">Learn more</a></div> </div> <div> <h3>Optum Clinical Claims Review (CCR) Pre-Pay Review Quick Reference Guide</h3> <div>Learn about the CCR pre-pay review process</div> <div><a href="/en/business/hcp-resources/page.hub5.clinical-claims-review-quick-reference-guide.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the Kansas City market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-kansas-city.html">Learn more</a></div> </div> <div> <h3>Optum Care ACE Smart Edits</h3> <div>Learn more about the Advanced Communication Engine and the edits currently in place.</div> <div><a href="/en/business/hcp-resources/page.hub5.ace-smart-edits.html">Learn more</a></div> </div> <div> <h3>Optum Care ACE quick reference guide</h3> <div>Get important details about the Advanced Communication System.</div> <div><a href="/en/business/hcp-resources/page.hub5.ace-reference-guide.html">Learn more</a></div> </div> <div> <h3>Provider quick reference guide</h3> <div>Get important details for the Ohio market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-reference-guide-ohio.html">Learn more</a></div> </div> <div> <h3>Optum-WA/OR care management referral form</h3> <div>This is a form for fax submissions.</div> <div><a href="/en/business/hcp-resources/page.hub5.care-management-referral-form-oregon.html">Learn more</a></div> </div> <div> <h3>Provider Claim Reconsideration Request Form</h3> <div>Challenge, appeal or request reconsideration of a claim. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-arizona.html">Learn more</a></div> </div> <div> <h3>Provider dispute resolution request</h3> <div>Complete this form to request a dispute resolution. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-california.html">Learn more</a></div> </div> <div> <h3>Prior authorization grid</h3> <div>View a list of CPT codes requiring a prior authorization for Wisconsin.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-grid-wi.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the South Carolina market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-south-carolina.html">Learn more</a></div> </div> <div> <h3>Online prior authorization submissions</h3> <div>View important benefits of submitting prior authorizations online using the prior authorization module (Curo)</div> <div><a href="/en/business/hcp-resources/page.hub5.online-prior-authorization-submissions.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request forms</h3> <div>Use these forms for the Wisconsin market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-wisconsin.html">Learn more</a></div> </div> <div> <h3>Prior authorization grid South Carolina</h3> <div>View a list of CPT codes requiring a prior authorization for South Carolina.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-grid-SC.html">Learn more</a></div> </div> <div> <h3>Prior authorization requirements for Optum Care Network–New Mexico</h3> <div>View the prior authorization process for New Mexico.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-requirements-new-mexico.html">Learn more</a></div> </div> <div> <h3>Benzodiazpines Prior Authorization Form</h3> <div>This is a Medicare form for benzodiazepines prior authorization requests.</div> <div><a href="/en/business/hcp-resources/page.hub5.benzodiazepines-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Prior authorization grid</h3> <div>View a list of CPT codes requiring prior authorization for Idaho</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-grid-idaho.html">Learn more</a></div> </div> <div> <h3>Medicare Part D Prior Authorization for Hospice Form</h3> <div>Use this form for hospice enrollees.</div> <div><a href="/en/business/hcp-resources/page.hub5.medicare-hospice-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Prior authorization grid</h3> <div>View a list of CPT codes requiring prior authorization for Utah</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-grid-utah.html">Learn more</a></div> </div> <div> <h3>Prior Authorization Request Form</h3> <div>This is a Medicare form for general PA requests.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-request-form.html">Learn more</a></div> </div> <div> <h3>Opioids & Medication Limits Prior Authorization Request Form-UnitedHealthcare Medicare only</h3> <div>Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.</div> <div><a href="/en/business/hcp-resources/page.hub5.opioid-medications-pa-form.html">Learn more</a></div> </div> <div> <h3>Prior authorization grid</h3> <div>View a list of CPT codes requiring prior authorization for Kansas City.</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-grid-kansas.html">Learn more</a></div> </div> <div> <h3>Opioids & Medication Limits Prior Authorization Request Form</h3> <div>Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.</div> <div><a href="/en/business/hcp-resources/page.hub5.opioids-medication-limits-pa-form.html">Learn more</a></div> </div> <div> <h3>Prescription Drug Reference Pricing Program</h3> <div>This form is for UFCW Plans only.</div> <div><a href="/en/business/hcp-resources/page.hub5.prescription-drug-reference-pricing.html">Learn more</a></div> </div> <div> <h3>Delaware Prior Authorization Form</h3> <div>The form is for UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.delaware-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>State of Arizona prior authorization form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.arizona-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Texas Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.texas-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Partial Copay Waiver (PCW) Exception Prior Authorization Request Form </h3> <div>This is for CalPERS Plan only. </div> <div><a href="/en/business/hcp-resources/page.hub5.partial-copay-waiver-exception.html">Learn more</a></div> </div> <div> <h3>Prior Authorization Form UHC</h3> <div>This form is for UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-form-uhc.html">Learn more</a></div> </div> <div> <h3>Massachusetts Prior General Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.massachusetts-general-pa.html">Learn more</a></div> </div> <div> <h3>Colorado Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.colorado-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Florida Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.florida-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Healthcare Reform Copay Waiver Request Form</h3> <div>This for is for UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.healthcare-reform-copay-waiver-uhc.html">Learn more</a></div> </div> <div> <h3>New Mexico Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.new-mexico-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Massachusetts Chemotherapy and Supportive Care PA Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.massachusetts-chemotherapy-supportive-care.html">Learn more</a></div> </div> <div> <h3>Prior authorization supporting documentation cover sheet</h3> <div>View the supporting documents (medical records) cover page for New Mexico</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-coversheet-nm.html">Learn more</a></div> </div> <div> <h3>Michigan Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.michigan-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Illinois Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.illinois-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Member Pays Difference Exceptions PA Form</h3> <div>This form is for CalPERS Plan only.</div> <div><a href="/en/business/hcp-resources/page.hub5.member-pays-difference-exceptions.html">Learn more</a></div> </div> <div> <h3>New Hampshire Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.new-hampshire-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Prior authorization supporting documentation cover sheet</h3> <div>View the supporting documents (medical records) cover page for Washington</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-coversheet-wa.html">Learn more</a></div> </div> <div> <h3>Prior Authorization Request Form</h3> <div>Use this form for Emergient North Dakota plan only.</div> <div><a href="/en/business/hcp-resources/page.hub5.pa-emergient-north-dakota.html">Learn more</a></div> </div> <div> <h3>Massachusetts Hepatitis-C Medications Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.massachusetts-heptatis-c-medications.html">Learn more</a></div> </div> <div> <h3>Prior Authorization Request Form</h3> <div>Use this form for Emergient Vermont Plan only.</div> <div><a href="/en/business/hcp-resources/page.hub5.pa-emergient-vermont.html">Learn more</a></div> </div> <div> <h3>Healthcare Reform Copay Waiver Request Form</h3> <div>This is for OptumRx (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.healthcare-reform-copay-waiver-request-form.html">Learn more</a></div> </div> <div> <h3>State of California prior authorization form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.california-authorization-form.html">Learn more</a></div> </div> <div> <h3>Oregon Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.oregon-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Optum Provider Change Form</h3> <div>Please use this form to request demographic updates, remit address changes, or updates to your practice information.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-change-form.html">Learn more</a></div> </div> <div> <h3>UHC West of California delegated medical group auto-authorization form</h3> <div>This form for UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.uhc-west-california-delegated-group-auto-authorization.html">Learn more</a></div> </div> <div> <h3>Massachusetts Synagis Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.massachusetts-synagis-pa-form.html">Learn more</a></div> </div> <div> <h3>Minnesota Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.minnesota-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Prior authorization supporting documentation cover sheet</h3> <div>View the supporting documents (medical records) cover page for Oregon</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-coversheet-or.html">Learn more</a></div> </div> <div> <h3>Cancer Guidance Program Contract Termination</h3> <div>Provider notification of change in how authorization is obtained for chemo therapy drugs</div> <div><a href="/en/business/hcp-resources/page.hub5.cancer-guidance-program.html">Learn more</a></div> </div> <div> <h3>Louisiana Prior Authorization Form</h3> <div>This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.louisiana-prior-authorization-form.html">Learn more</a></div> </div> <div> <h3>Rhode Island Prior Authorization Form</h3> <div>This form is for UnitedHealthcare (non-Medicare).</div> <div><a href="/en/business/hcp-resources/page.hub5.rhode-island-prior-authorization.html">Learn more</a></div> </div> <div> <h3>EDI Companion Guide</h3> <div>HIPAA Companion Guides describe Optum Rx specific technical details for EDI transactions.</div> <div><a href="/en/business/hcp-resources/page.hub5.edi-837-companion-guide.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form - APN</h3> <div>Challenge, appeal or request reconsideration of a claim. </div> <div><a href="/en/business/hcp-resources/page.hub5.provider-dispute-resolution-form-connecticut-apn.html">Learn more</a></div> </div> <div> <h3>Submitting an electronic prior authorization (e-PA)</h3> <div><a href="/en/business/hcp-resources/page.hub5.electronic-prior-authorization.html">Learn more</a></div> </div> <div> <h3>Prior authorization list (BCBS)</h3> <div>Get a list of codes for Optum Care-Arizona (BCBS Members).</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-list-arizona-bcbs.html">Learn more</a></div> </div> <div> <h3>Provider claim reconsideration request form</h3> <div>Use these forms for the Ohio market.</div> <div><a href="/en/business/hcp-resources/page.hub5.provider-claim-reconsideration-request-form-ohio.html">Learn more</a></div> </div> <div> <h3>SNF list</h3> <div>Providers directing community SNF admissions should reference the Arizona contracted SNF list.</div> <div><a href="/en/business/hcp-resources/page.hub5.snf-list-arizona.html">Learn more</a></div> </div> <div> <h3>Prior authorization supporting documentation cover sheet</h3> <div>View the supporting documents (medical records) cover page for Arizona, Colorado, Idaho, Kansas City, Nevada, and Utah</div> <div><a href="/en/business/hcp-resources/page.hub5.prior-authorization-coversheet-mtw.html">Learn more</a></div> </div> <div> <h3>Optum Care management intake form</h3> <div>To refer to Optum Care management, submit a completed intake form.</div> <div><a href="/en/business/hcp-resources/page.hub5.optum-care-management-intake-form.html">Learn more</a></div> </div> <div> <h3>Prior authorization requirements for Optum APN-Connecticut</h3> <div>View the prior authorization process for Connecticut.</div> <div><a href="/en/business/hcp-resources/page.hub5.ct-prior-authorization-grid.html">Learn more</a></div> </div> <div> <h3>Authorization to use and disclose protected health information</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.phi-authorization-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Primary care provider referral form</h3> <div>View the Optum Care–Utah provider referral form.</div> <div><a href="/en/business/hcp-resources/page.hub5.primary-care-provider-referral-form-utah.html">Learn more</a></div> </div> <div> <h3>Request for access to protected health information</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.phi-access-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Request to restrict use and disclosure of protected health information</h3> <div>Please complete and return the form to the requesting department.</div> <div><a href="/en/business/hcp-resources/page.hub5.phi-restrict-use-infusion-pharmacy.html">Learn more</a></div> </div> <div> <h3>Specialist referral form</h3> <div>Get a referral form for specialists in Arizona.</div> <div><a href="/en/business/hcp-resources/page.hub5.specialist-referral-form.html">Learn more</a></div> </div> </div> </div> </div> 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