Use this form to notify OptumHealth Care Solutions of your 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION 1 – REFERRAL INFORMATION. Enter the date, your referring case manager's name, and their telephone number.
3. Move to SECTION 2 - BENEFIT INFORMATION (OPTIONAL). Fill in any applicable details regarding deductible, copay, out-of-pocket maximum, and lifetime maximum.
4. In SECTION 3 – PATIENT INFORMATION, provide comprehensive details about the patient including their name, relationship to the insured, group number, policy holder information, address, phone number, date of birth, and social security number.
5. Continue with claims information in SECTION 3 - CLAIMS INFORMATION. Input the claims mailing contact details and status contact information.
6. Proceed to SECTION 4 - MEDICAL INFORMATION. Document primary and related diagnoses along with medical history and treatment facility details.
7. Finally, review SECTION 5 - OTHER INFORMATION for any additional notes or requirements before submission.

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