Forms for
Specialty Medications
Find the referral form you need by specialty or medication.
If a specific form is not listed, select the appropriate general form below.
Infusion Referral Forms
Specialty Pharmacy Referral Forms
For Providers
-
Use this form to request infusion supplies for an OptiMed patient.
Download the Infusion Supply Request Form
Check each supply needed.
Enter the amount currently On Hand and the amount Needed.
Complete any Specify fields that apply.
Email the completed form to InfusionTeam@optimedhp.com (preferred) or fax it to 877-326-2856.
-
If a medication request has been denied, providers may submit an appeal for reconsideration. Please complete the Appeal Request Form, attach all required documentation, and return it via fax within seven (7) business days.
For Patients
-
Use this form to give OptiMed permission to share your medical and/or financial information with another person, provider, or organization.
Complete all required sections, sign and date the form, and return it to OptiMed.
If someone other than the patient signs the form, proof that they are the patient’s legal representative must also be included, unless they are a parent signing for a child under 18.
Additional resources
OptiMed provides complimentary shipping and handling of all medications and supplies. Expedited shipping may result in a small fee. Home infusion may be an option for some patients. The site of care will be determined based on the patient’s medical provider(s), medical status, safety considerations of the medication, drug labeling, and payer specifications.
Call OptiMed at (877) 232-2857 to see if you’re eligible for Home Infusion Therapy.