Forms and Documents

 

Some of our most-requested forms are available for you to view and print online.  Our downloadable forms require Adobe Reader in order to view and print.  Get Adobe Reader.

Advance Directive

 Advance Directive Form

Advanced Imaging Authorization Forms

 CT/CTA Authorization Form

 MRI/MRA Authorization Form 

 PET/Spectroscopy Authorization Form

 Sentara Medical Solutions Form

Billing Services

 Billing Services Form Instructions

 Billing Services Form

Diabetes

 Diabetes Supply Order Form

DME

 DME Authorization Form 

 

Drug Authorization Forms

(Need an authorization for an Optima Medicare Preferred Plus member?  Visit Medicare Drug Authorization Forms.) 

 

 Aceon Authorization

 Achthar Gel Authorization

 Actiq Authorization

 Adderall XR Authorization

 Ambien CR Authorization

 Amevive Authorization

 Aranesp Authorization

 Atacand/Atacand HCT Authorization

 Avapro/Avalide Authorization

 Avastin Authorization

 Avonex Authorization

 Azor Authorization

 Benicar/Benicar HCT Authorization

 Betaseron Authorization

 Boniva IV Authorization

 Botox Authorization

 Brovana Authorization

 Byetta Authorization

 Caduet Authorization

 Celebrex Authorization

 Cozaar/Hyzaar Authorization

 Crestor Authorization

 Cymbalta Authorization

 Daytrana Authorization

 Desoxyn Authorization

 Differin Authorization

 Diovan/Diovan HCT Authorization

 Effexor XR Authorization

 Emsam Authorization

 Enbrel Authorization

 Epogen Authorization

 Euflexxa Authorization

 Exforge Authorization

 Fentora Authorization

 FluMist Authorization

 Focalin XR Authorization

 Growth Hormone Authorization

 Hyalgan Authorization

 Humira Authorization

 Implanon Authorization

 Invega Authorization

 IVIG Authorization

 Janumet Authorization

 Januvia Authorization

 Kepivance Authorization

 Keppra Authorization

 Kineret Authorization

 Lescol, XL Authorization

 Leukine Authorization

 Lexapro Authorization

 Lipitor Authorization

 Lovaza Authorization

 Lucentis Authorization

 Lunesta Authorization

 Lyrica Authorization

 Macugen Authorization

 Medical Necessity Request Form

 Metadate CD Authorization

 Micardis/Micardis HCT Authorization

 Neulasta Authorization

 Neumega Authorization

 Neupogen Authorization

 Nexavar Authorization

 Norfolk Consortium For Smoking Cessation

 Opana ER Authorization

 Opana Authorization

 Orencia Authorization

 Orthovisc Authorization

 Oxycontin Authorization

 Paxil CR Authorization

 Pegasys Authorization

 Perforomist Authorization

 Pharmacy Pre-Authorization

 PharmaCare Request Form for Injectables

 PPI Step-Edit/Prior Authorization Request Form

 Prialt Authorization

 Procrit Authorization

 Provigil Authorization

 Raptiva Authorization

 Reclast Authorization

 Remicade Authorization

 Retin-A Authorization

 Revatio Authorization

 Revlimid Authorization

 Risperdal Consta Authorization

 Ritalin LA Authorization

 Rituxan Authorization

 Rozerem Authorization

 Sandostatin Authorization

 Serostim Authorization

 Singulair Authorization

 Sonata Authorization

 Stadol Authorization

 Strattera Authorization

 Supartz Authorization

 Sutent Authorization

 Symlin Authorization

 Synagis Authorization

 Synarel Authorization

 Synvisc Authorization

 Tekturna/Tekturna HCT Authorization

 Teveten/Teveten HCT Authorization

 Tykerb Authorization

 Thyrogen Authorization

 Torisel Authorization

 Tysabri Authorization

 Vectibix Authorization

 Vivaglobin Authorization

 Vytorin Authorization

 Vyvanse Authorization

 Wellbutrin XL Authorization

 Xolair Authorization

 Xopenex Authorization

 Zetia Authorization

 

Drug Lists

 Preferred and Standard Drug List

 Optima Medicare Drug List

 Optima Medicare Appeal and Grievance Process

 Prior Authorization, Step-Edit and Quantity Limits Drug List

 Generics Plus Formulary

Electronic Funds/Remittance Transfers

 EDI Transaction Overview

 EDI Setup form - Providers

GYN Authorization

 GYN Procedure Request Form

Lab

 In-Office Lab List 

Medical Record Documentation Standards

 Medical Record Documentation Standards

NPI Submission 

 NPI Information

 NPI Online Submission

 NPI Submission Form

 NPI Contingency Plan

OB Forms

 OB Certification Form

Oxygen

 Medical Necessity Ordering Form for Oxygen

Pediatric

 Pediatric Health Maintenance Guidelines

 Recommendations for Preventive Pediatric Health Care (EPSDT)

Pharmacy Order Forms

 PharmaCare Request Form for Injectables

 Caremark Mail Service Form

 Mirena Eligibility Form

 Mirena Order Form

Pre-Existing Condition 

 Pre-Existing Condition Form

Provider Connection Forms

 Minimum system requirements

 Provider Connection Optima Health Enrollment Form

 

Reconsiderations

(Do not use this form for Medicare claims. Medicare guidelines for claim reconsiderations require a new claim be submitted.)

 

 Provider Reconsideration Form

Referral and Authorization Request

 Referral and Authorization Request Form

 Authorization Request Form

 Medicare Part D Coverage Determination Request Form

Release of Information

 Release of Information Form

Site Evaluation

 PCP/OB/Gyn Practice Site Evaluation Form

Therapy

 Authorization for Therapy Worksheet

Transitional Care Request Form

 Transitional Care Request Form

Well Child Forms

 Well Child and Adolescent Well Child Forms

Last Updated June 20, 2008 8:06:35 AM