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 (2009)

 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 member?  Visit Medicare Drug Authorization Forms.) 

 

 17-P Authorization

 Abilify Authorization

 Aceon Authorization

 Achthar Gel Authorization

 Aciphex Authorization

 Actiq Authorization

 Adipex-P Authorization

 Adderall XR Authorization

 Ambien CR Authorization

 Amerge Authorization

 Amevive Authorization

 Aranesp Authorization

 Atacand/Atacand HCT Authorization

 Avalide Authorization

 Avapro Authorization

 Avastin Authorization

 Avonex Authorization

 Axert Authorization

 Azor Authorization

 Banzel Authorization

 Benicar/Benicar HCT Authorization

 Betaseron Authorization

 Boniva IV Authorization

 Botox Authorization

 Caduet Authorization

 Celebrex Authorization

 Cimzia Authorization

 Cozaar Authorization

 Crestor Authorization

 Cymbalta Authorization

 Daytrana Authorization

 Differin Authorization

 Diovan/Diovan HCT Authorization

 Edluar Authorization

 Effexor XR Authorization

 Enbrel Authorization

 Epogen Authorization

 Euflexxa Authorization

 Exforge Authorization

 Fentora Authorization

 FluMist Authorization

 Focalin XR Authorization

 Frova Authorization

 Geodon Authorization

 Growth Hormone Authorization

 Hyalgan Authorization

 Hyzaar Authorization

 Humira Authorization

 Imitrex Authorization (for brand)

 Implanon Authorization

 Invega Authorization

 Ionamin Authorization

 IVIG Authorization

 Kepivance Authorization

 Kapidex Authorization

 Keppra XR Authorization

 Kineret Authorization

 Lescol, XL Authorization

 Leukine Authorization

 Lexapro Authorization

 Lipitor Authorization

 Lovaza Authorization

 Lunesta Authorization

 Luvox CR

 Lyrica Authorization

 Maxalt Authorization

 Maxalt-MLT Authorization

 Medical Necessity Request Form

 Meridia Authorization

 Metadate CD Authorization

 Micardis/Micardis HCT Authorization

 Neulasta Authorization

 Neumega Authorization

 Neupogen Authorization

 Nexavar Authorization

 Nexium Authorization

 Norfolk Consortium For Smoking Cessation

 Nucynta Authorization

 Nuvigil Authorization

 Onglyza Authorization

 Opana ER Authorization

 Opana Authorization

 Orencia Authorization

 Orthovisc Authorization

 Oxycontin Authorization

 Paxil CR Authorization

 Pharmacy Pre-Authorization

 PharmaCare Request Form for Injectables (2009)

 Prevacid Authorization

 Prialt Authorization

 Pristiq Authorization

 Procrit Authorization

 Protonix Authorization

 Provigil Authorization

 Reclast Authorization

 Relistor Authorization

 Remicade Authorization

 Retin-A Authorization

 Revatio Authorization

 Revlimid Authorization

 RhoD Authorization

 Risperdal PO Authorization

 Risperdal Consta Authorization

 Ritalin LA Authorization

 Rituxan Authorization

 Rozerem Authorization

 Samsca Authorization

 Sandostatin Authorization

 Savella Authorization

 Seroquel Authorization

 Serostim Authorization

 Simcor Authorization

 Singulair Authorization

 Sonata Authorization

 Stadol Nasal Spray Authorization

 Strattera Authorization

 Supartz Authorization

 Sutent Authorization

 Symlin Authorization

 Synagis Authorization (2009)

 Synarel Authorization

 Synvisc Authorization

 Synvisc-One Authorization

 Tekturna/Tekturna HCT Authorization

 Teveten/Teveten HCT Authorization

 Tykerb Authorization

 Thyrogen Authorization

 Torisel Authorization

 Treximet Authorization

 Trilipix Authorization

 Tysabri Authorization

 Ulesfia Authorization

 Vectibix Authorization

 Vimpat Authorization

 Vivaglobin Authorization

 Vytorin Authorization

 Vyvanse Authorization

 Xenical Authorization

 Xolair Authorization

 Xopenex Authorization

 Zegerid Authorization

 Zomig Authorization

 

Drug Lists

 Preferred and Standard Drug List

 2010 Optima Medicare (PPO) Drug List

 2009 Optima Medicare (PPO) Drug List

 Optima Medicare (PPO) Appeal and Grievance Process

 Prior Authorization, Step-Edit and Quantity Limits Drug List

 Generics Plus Formulary

 Optima Health Injectable & Infusion Medication List

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

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

Private Duty Nursing Request Forms

 Private Duty Nursing Request Form (COVA Connect Only)

 Private Duty Nursing Request Form (Optima Family Care Only)

Provider Connection Forms

 Minimum system requirements

 Provider Connection Optima Health Enrollment Form

Reconsiderations

 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 

 EPSDT Coding Reference Sheet (New)

 

Last Updated March 10, 2010 1:38:03 PM