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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, …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 Address

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