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Long term care pharmacy attestation form

Use this form to enter your attestation to the CMS requirement

LTC Pharmacy Attestation - Alternate Processing

Instructions:

  • Pharmacy must review the attestation form
  • Fill out the pdf form with your company name, NCPDP #, signature, name, title, and date
  • For additional questions, contact Independent Contracting at independent.contracting@optum.com

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