104-0006 (ORX5510F_120601 + UHC) FORM_Fax.indd-2026

1. Click ‘Get Form’ to open the document in the editor.
2. Begin by filling out Section 1, which is 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 designated area.
4. In Section 2, the prescribing physician should complete their information including their name, phone number, fax number, and address. Ensure they enter prescription details or attach an office prescription.
5. Finally, the physician must sign and date the form before faxing it to OptumRx at the provided number. Make sure all sections are filled accurately to avoid delays.

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