Signup for Prior Authorization Services

Practice/Physician Name*
Clinic Contact Name*
Zip Code*
NPI Number*
Phone*
Fax*
Email*
Tax ID*
Do you accept the BAA?see www.mygenomemylife.org/baa
Access/Referral code*
Optum ID*: Provide if participating. Enter N/A if not.
AIM Username*: Provide if participating. Enter N/A if not.
Optum Password
AIM Password
Availity ID: Provide if participating. Enter N/A if not.
Availity Password
Notes
IP Address

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