Virginia Beach, VA 23462
1-844-512-3172 | OHCC and DSNP
1-800-229-8822 | Medicare and OFC
Authorization status can be checked at optimahealth.com or by
calling Provider Relations.
Government Programs: Authorization Request for
Future Inpatient and Outpatient Services
Optima Medicare Advantage | Optima Community Complete (DSNP)
Optima Health Community Care | Optima Family Care
_________________________________________
Please submit via fax to 757-963-9623 or 1-844-348-3720
Member Name / Last, First Member ID / Policy # Date of Birth / Age
The below information and pertinent medical notes are required to process your request:
□ Out of Are a Re quest □ Inpatient Admission □ Outpatient Service □ 23 Hour OBS
Date of Service____/____/____
Diagnosis Codes: Diagnosis Description:
Procedure Codes:
_______________/_________________/_________________/________________/___________________
Procedure Description:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Provider Information
Full Name of Ordering Physician: _________________________________Specialty _____________________
Optima Provider #____________________NPI # ______________________ Tax ID # ___________________
Servicing Provider/Hospital/Facility: ___________________________________________________________
Optima Provider # ____________________ NPI # ______________________ Tax ID # __________________
Person Completing Form: _________________________Phone: __________________ Fax: ______________
