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Get 2016 Optumrx Prior Authorization Form

Provider Information (required) Member Name: Provider Name: Insurance ID#: NPI#: Date of Birth: Office Phone: Street Address: Office Fax: City: State: Phone: Zip: Specialty: Office Street Address: City: State: Zip: Medication Information (required) Medication Name: Strength: Is This Medication a New Start? Yes No Dosage Form: Directions for Use: Clinical Information (required) Select the diagnosis below: Type 2 diabetes mellitus Other diagnosis:.

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