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Physician Fax Order Form

This document is a new prescription order form for a mail service pharmacy. It contains sections for the member to provide their contact and health information, and for the prescribing physician to provide prescription details, refill instructions, and a signature. The physician must fax the completed form to the pharmacy's number in order for the new prescription to be filled and mailed to the member.

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Anna
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565 views1 page

Physician Fax Order Form

This document is a new prescription order form for a mail service pharmacy. It contains sections for the member to provide their contact and health information, and for the prescribing physician to provide prescription details, refill instructions, and a signature. The physician must fax the completed form to the pharmacy's number in order for the new prescription to be filled and mailed to the member.

Uploaded by

Anna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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New Prescription PHYSICIAN FAX Order Form

Use this form to order a new mail service prescription by fax from the prescribing physician’s office. Member completes section 1,
while the physician completes sections 2 and 3. This fax is void unless received directly from physician’s office. To contact
OptumRx, physicians may call 1-800-791-7658.

1 Member information — to be completed by member


Member ID Number (Additional coverage, if applicable)
Secondary Member ID Number
Last Name First Name MI

Delivery Address Apt. #

City State ZIP Phone Number with Area Code

Date of Birth (mm/dd/yyyy) Gender Email


M F
Medication Allergies:  Aspirin  Erythromycin  Quinolones  Others: 
 None known  Cephalosporins  NSAIDs  Sulfa 
 Amoxil/Ampicillin  Codeine  Penicillin  Tetracyclines 
Health Conditions:  Asthma  Glaucoma  High cholesterol  Others: 
 None known  Cancer  Heart condition  Osteoporosis 
 Arthritis  Diabetes  High blood pressure  Thyroid Disease 
Over-the-counter/herbal medications taken regularly:

Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here:

Notes to pharmacy:

2 Physician and prescription information — physician to complete this section


Prescribing Physician Name Patient Name DOB

Physician Phone Number with Area Code


Enter prescription details here or attach
your office prescription to the form.
Physician Fax Number with Area Code

Physician Street Address

City, State, ZIP

NPI DEA

This document and others if attached contain information from OptumRx


that is privileged, confidential and/or may contain protected health
information (PHI). We are required to safeguard PHI by applicable law. The
information in this document is for the sole use of the person(s) or company
named above. Proper consent to disclose PHI between these parties has
been obtained. If you received this document by mistake, please know Refills:  1  2  3  Other: __________________________
that sharing, copying, distributing or using information in this document
is against the law. If you are not the intended recipient, please notify the
Dispense as written:  Yes
sender immediately and return the document(s) by mail to OptumRx Privacy
Office, 17900 Von Karman, M/S CA016-0101, Irvine, CA 92614. X_______________________________________ _____________
Physician Signature Date
3 Physician to fax completed order form to OptumRx at 1-800-491-7997.

ORX5510_130903
104-0006 9/13
10852

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