Please complete this form within the specified timeframe. All PSF submissions should be completed online at www.myoptumhealthphysicalhealth.com unless other- Please review the Plan Summary for more information. 1. Name of the billing provider or facility (as it will appear on the claim form) 2. Federal tax ID(TIN) of entity in box #1. 3.

Patient Summary Form (PSF-750) The Patient Summary Form is used by providers to document the status of the patient and the need for services. OptumHealth uses this form to review patient eligibility and to enter demographic and clinical data in to our Clinical Information System.

PSF-750 (Rev: 7/1/2015) Please complete this form within the specified timeframe. All PSF submissions should be completed online at www.myoptumhealthphysicalhealth.com unless other- Please review the Plan Summary for more information. 1. Name of the billing provider or facility (as it will appear on the claim form) 2.

submission consists of the Patient Summary Form 750 with both the provider and patient sections completed. Functional outcome measures, while highly recommended, are optional forms.

Please complete this form within the specified timeframe. All PSF submissions should be completed online at www.myoptumhealthphysicalhealth.com unless other- Please review the Plan Summary for more information. 1. Name of the billing provider or facility (as it will appear on the claim form) 2. Federal tax ID(TIN) of entity in box #1. 3.

Submit a PSF electronically – Administrative Corrections. If you need to make a change to a previously submitted PSF, either before or after you receive a determination letter, you can do so directly on the site. Simply pull up a new PSF-750 form, pick your patient or type in the patient’s demographics and then click check box for ‘Is this an

Please complete this form within the specified timeframe. All PSF submissions should be completed online at www.myoptumhealthphysicalhealth.com unless other- Please review the Plan Summary for more information. 1. Name of the billing provider or facility (as it will appear on the claim form) 2. Federal tax ID(TIN) of entity in box #1. 3.

Sign and share Patient summary form united healthcare together with any other business and personal paperwork online without wasting time and resources on printing and postal delivery. Get the most out of our online form editor using a built-in compliant eSignature option.

Please complete this form within the specified timeframe. All PSF submissions should be completed online at www.myoptumhealthphysicalhealth.com unless other- Please review the Plan Summary for more information. 1. Name of the billing provider or facility (as it will appear on the claim form) 2. Federal tax ID(TIN) of entity in box #1. 3.