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Optum Specialty Phone: 877-445-6874 | Optum Specialty Fax: 877-342-4596 . Specialty Pharmacy Enrollment Form This form is not a valid prescription in Arizona . Please detach before submitting to a pharmacy – tear here . PATIENT INFORMATION PRESCRIBER INFORMATION . Please complete the following or send patient demographic sheet View Michelle Hoang's professional public profile. Doximity is the leading professional network exclusively for Physicians. Claim your profile. 1-877-342-4596 Call 1-877-445-6874 Ready to prescribe? Just e-prescribe, fax or call in your patient’s prescription to Optum® Specialty Pharmacy. We’ll handle the rest. Once we receive the prescription, we will: • Complete a benefits investigation and prior authorization • Aid patients in obtaining financial assistance programs

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Optum Specialty Phone: 877-445-6874 | Optum Specialty Fax: 877-342-4596 Please detach before submitting to a pharmacy – tear here PATIENT INFORMATION PRESCRIBER INFORMATION Please complete the following or send patient demographic sheet Prescriber’s Name Patient Name DEA/NPI Address Group / Hospital City, State, ZIP Address1-877-231-8302 FAX NUMBER 1-877-732-3431 1-888-347-3416 PHONE NUMBER ... Optum Specialty Pharmacy 1-877-445-6874 1-877-342-4596 *This table is current as of 08/01 ...

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