OptumCare Prior Authorization Form
PRIOR AUTHORIZATION FORM Phone: (877) 370-2845 opt 2 Fax: (888) 992-2809 1 of 2 . Instructions: • Please complete the form located on page two. Fields with an asterisk ( * ) are required. • Please include all clinical information, x-ray reports, and diagnostic test results supportive of the procedure(s) requested ................
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