2012 OPTUMRx 104-0006-2026

1. Click ‘Get Form’ to open the 2012 OPTUMRx 104-0006 in the editor.
2. Begin by filling out Section 1. Enter your Primary Member ID Number and, if applicable, your Secondary Member ID Number. Provide your First Name, Last Name, Middle Initial, Delivery Address, City, State, ZIP Code, Date of Birth (mm/dd/yyyy), Gender, Phone Number with Area Code, and Email.
3. Indicate any Medication Allergies by checking the appropriate boxes. If you have additional allergies not listed, write them in the space provided.
4. Next, specify any Health Conditions you may have by selecting from the options provided or writing in others as necessary.
5. In the section for Over-the-counter/Herbal medications taken regularly, list any medications you wish to keep on file.
6. Section 2 is for your physician. Ensure they complete this section or attach their office prescription before faxing it to the designated number.

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