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The form requests member identity and contact information, provider identity including NPI and practice contact details, medication name with strength and dosage form, and whether the medication is a new start. It also requires diagnosis information with ICD-9/10 codes, previous therapies tried and failed, and supporting lab or test results, plus additional physician comments as needed.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/optumrx-prior-authorization-request-form/287454/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/optumrx-prior-authorization-request-form/287454.png","ImageObject",442,249,{"name":88,"@type":89},"Aditya","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required about the member on this form?","Question",{"text":108,"@type":109},"The form requests member name, insurance ID number, date of birth, street address, city, state, zip, and phone.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What provider details must be included?",{"text":113,"@type":109},"Provider name, NPI, specialty, office phone and fax, and office street address, city, state, and zip are required.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical and medication information does the physician need to provide?",{"text":117,"@type":109},"The form requires medication name plus strength and dosage form, directions for use, whether it is a new start, patient diagnosis with ICD-9/10 codes, prior medications tried and failed, supporting labs or test results, and any additional comments the physician considers important.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287454,1789632347,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},962085564549,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Please note: All information below is required to process this request For urgent requests please call 1-800-711-4555  \nMon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific  \nFor real time submission 24/7 visit [www.OptumRx.com](www.OptumRx.com) and click Health Care Professionals OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626  \nPrior Authorization Request Form  \n\n| Member Information (required) |  |  | Provider Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  | Specialty: |  |\n| Date of Birth: |  |  | Office Phone: |  |  |  |\n| Street Address: |  |  | Office Fax: |  |  |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |\n| Phone: |  |  | City: | State: |  | Zip: |\n| Medication Information (required) |  |  |  |  |  |  |\n| Medication Name: |  |  | Strength: |  | Dosage Form: |  |\n| Is This Medication a New Start? 􀂉Yes 􀂉No |  |  | Directions for Use: |  |  |  |\n| Clinical Information (required) |  |  |  |  |  |  |\n| What is the patient’s diagnosis?\u003Cbr>ICD-9/10 Code(s):   |  |  |  |  |  |  |\n| What medication(s) has the patient tried and failed? |  |  |  |  |  |  |\n| Are there any supporting labs or test results? (Please specify) |  |  |  |  |  |  |\n\nAre there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?  \n________________________________________________________________________________________________________________  \n________________________________________________________________________________________________________________  \nPlease note: This request may be denied unless all required information is received.  \nIf the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555.  \nFor urgent or expedited requests please call 1-800-711-4555.  \nThis form may be used for non-urgent requests and faxed to 1-800-527-0531.","cbCaihLdzQxqTSrL","https://ap.wps.com/l/cbCaihLdzQxqTSrL","pdf",31754,"English","# Member Information\n# Provider Information\n# Medication Information\n# Clinical Information\n# Additional Physician Comments","[{\"question\":\"What information is required about the member on this form?\",\"answer\":\"The form requests member name, insurance ID number, date of birth, street address, city, state, zip, and phone.\"},{\"question\":\"What provider details must be included?\",\"answer\":\"Provider name, NPI, specialty, office phone and fax, and office street address, city, state, and zip are required.\"},{\"question\":\"What clinical and medication information does the physician need to provide?\",\"answer\":\"The form requires medication name plus strength and dosage form, directions for use, whether it is a new start, patient diagnosis with ICD-9/10 codes, prior medications tried and failed, supporting labs or test results, and any additional comments the physician considers important.\"}]","OptumRx Prior Authorization Request Form | PDF"]