Movantik Prior Authorization Request Form Member ... - OptumRx: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID number, date of birth, and contact details.
Next, complete the 'Provider Information' section. Input the provider's name, NPI number, office phone, and address.
In the 'Medication Information' section, specify the medication name, strength, dosage form, and whether you are requesting a brand version.
Indicate if this is a continuation of therapy by selecting 'Yes' or 'No.' If 'Yes,' answer additional questions regarding previous medication use.
Fill out the 'Clinical Information' section by selecting the appropriate diagnosis and providing any necessary comments or additional information.
Review all entered information for accuracy before submitting. Ensure that all required fields are completed to avoid delays in processing.

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