104-0006 (ORX5510F_120601 + UHC) FORM_Fax.indd-2025

1. Click ‘Get Form’ to open the document in the editor.
2. Begin by filling out Section 1, which is designated for member information. Enter your Member ID Number, Last Name, First Name, and other personal details such as Date of Birth and Gender.
3. Indicate any medication allergies and health conditions by checking the appropriate boxes. If you take over-the-counter or herbal medications regularly, list them in the provided space.
4. Proceed to Section 2 where the prescribing physician will enter their information. Ensure they provide their name, phone number, fax number, and address.
5. In this section, the physician should also enter prescription details or attach an office prescription if necessary.
6. Finally, ensure that the physician signs and dates the form before faxing it to OptumRx at the specified number.

Start using our platform today for free to streamline your document editing and form completion!