Long term care pharmacy attestation form

Use this form to enter your attestation to the CMS requirement


LTC Pharmacy Attestation - Alternate Processing


  • Pharmacy must review the attestation form
  • Fill out the pdf form with your company name, NCPDP #, signature, name, title, and date
  • For additional question contact Pharmacy Provider Relations at 877-633-4701 or email provider.relations@optum.com

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