Forms and resources for patients
Personal representatives form
Use this form to identify a person who can make decisions about your healthcare, request and disclose your PHI or exercise your rights on your behalf.
Optum Medical Care credit card authorization form
A credit card authorization form is available and may be reviewed during your visit.
Advance beneficiary notice of noncoverage
Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to Optum Specialty Pharmacy. Please complete and return the form to the requesting department.
NWP medical record transfer forms
Find forms for requesting medical record transfers to and from providers.
Finding the right Medicare plan for you
Use our checklist to assess your health needs and what matters to you. Based on your answers, a licensed insurance agent can help you find the right Medicare plan.
Specialty Pharmacy Community Residency
This 12-month post-graduate program offers a unique community practice environment to develop expertise in specialty pharmacy.
Patient rights and responsibilities
Please complete these forms before your first visit with your doctor.
Better financial health and improved operations
Improve cost optimization by controlling fixed costs, increasing efficiency and enabling organizational flexibility and agility.
Request to restrict use and disclosure of Protected Health Information (PHI)
Complete and return this form if you would like to request restrictions on certain uses and disclosures of your PHI.
Request for confidential communications at an alternative address or by another means
Complete and return this form if you would like to request confidential communications at an alternative address.
Request to amend protected health information
Complete and return this form if you would like to amend the records Optum Specialty Pharmacy maintains about you if they are inaccurate or incomplete.
State consumer privacy notice
Depending on which Optum product or service you use, and your state of residency, you may have rights as outlined in this Notice.
PHI Non-Routine Disclosure – Infusion
Complete and return this form if you would like to receive an accounting of certain disclosures of PHI made by Optum Infusion Pharmacy.
PHI Restriction – Infusion
Complete and return this form if you would like to request restrictions on certain uses and disclosures of your PHI from Optum Infusion Pharmacy.
Optum East MSSP accountable care organization
Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) help people with Traditional Medicare receive high-quality care.
Notice of privacy practices
This notice describes how your medical information can be used and shared. It also describes how you can get access to this information.
Request for access to protected health information
Complete and return this form if you would like to access and inspect the information Optum Specialty Pharmacy maintains and uses to make decisions about the services we provide you.
Medical record release authorization – Utah and Idaho
We use this form to obtain your written authorization to disclose your PHI to someone designated by you.
Optum Medical Care release of health information
Request medical records using a paper form.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
PHI Access Request – Infusion
Complete and return this form if you would like to access and inspect the information Optum Infusion Pharmacy maintains and uses to make decisions about the services we provide you.
Medical record release authorization – Colorado
We use this form to obtain your written authorization to disclose your PHI to someone designated by you.
Optum Medical Care code of conduct
In this Code of Conduct for New York and New Jersey, learn about the principles of integrity and ethical behavior so that we always strive to do the right thing.
Optum Medical Care release of health information
Request medical records using a paper form.
Manufacturer PHI authorization form
We use this form to obtain your written consent to disclose your protected health information to pharmaceutical manufacturers, patient support programs, and their authorized agents. This request does not allow those parties to make any of your treatment decisions or direct care decisions. The form also allows the pharmacy to receive additional compensation for using and disclosing your protected health information (PHI).
Authorization revocation notice
Cancel a previous authorization using this form. Limit the release of your information and take control of your health care decisions today.
Advance beneficiary notice of noncoverage (ABN) Spanish
Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to Optum Specialty Pharmacy. Please complete and return the form to the requesting department.
Financial assistance form
Apply for financial assistance to manage your health care costs. Get the support you need and submit your form today.
Comparison chart: Medicare vs. Medicare Advantage
Use this easy-to-read chart to compare Original Medicare and Medicare Advantage plans. Take the next step to finding the coverage that fits your needs.
Request for an accounting of non-routine disclosures of protected health information
Complete and return this form if you would like to receive an accounting of certain disclosures of PHI made by Optum Specialty Pharmacy.
Nevada Accountable Care Organization (ACO)
Optum Care ACO West is part of Medicare's Accountable Care Organization (ACO) program. Get important information about the ACO.
Personal representatives form Spanish
Use este formulario para identificar una persona que pueda tomar las decisiones sobre su atención de la salud, solicitar y divulgar su información de salud protegida, o ejercer sus derechos en su nombre.
Streamline Medicaid Eligibility and Enrollment
The rise of healthcare consumerism has prompted many hospitals and health systems to rethink their patient satisfaction strategies.
Standard PHI authorization form
Use this form to consent to the release of verbal or written PHI, including your profile or prescription records, to your designated person, named in the form.
New patient form
Download and fill out the health assessment and insurance information form.
Member reimbursement claim form
Please use this form to ask to be reimbursed for care you paid for.
Advance cost estimate notice
This notice explains our policy to provide a good faith estimate of expected charges prior to receiving services, for patients that might be uninsured or self-pay.
Medical release form
Safely share your medical records. Be confident knowing your health information is being sent according to your wishes.
Specialty financial assistance
Everyone should be able to access the treatments they need. We're here to help you find ways to access and afford your medication.
Specialty Pharmacy Texting Terms of Use
Surprise billing protection
Learn more about your rights and protections against receiving surprise medical billing from providers in the state of Washington.
MyChart child proxy form
Get access to your child’s health records. Complete and return this MyChart proxy form to stay connected to your child's care and updates.
Medicare Shared Savings Program
Learn more about the Optum California ACO and the high-quality care we offer Medicare patients.
Optum Medical Care billing notifications
If you are no longer receiving paper statements, it is possible you may have left the “Simplify. Go paperless.” option checked. See how you can modify your paperless settings.
Patient rights and responsibilities
This document explains your rights and responsibilities as an Optum patient.
Formulario de nuevo paciente
Descargue y llene el formulario de evaluación de salud e información de seguro aquí.
Request for alternative means of confidential communications
Control how and where you receive confidential communications. Use this form to request alternative methods for communication. Ensure your privacy preferences are honored.
Patient consent and assignment of benefits (AOB)
Form that designates Optum Specialty Pharmacy as an approved provider for a member's Medicare Part B eligible medications. Please complete and return the form to the requesting department.
Standard PHI authorization form Spanish
Use este formulario para dar su consentimiento para la divulgación de la información de salud protegida tanto verbal como escrita, que incluye su perfil o registro de recetas, a la persona que usted haya designado en el formulario.
Records request form
Download and fill out this form form to ask to send your records to another location.
Authorization for treatment of a minor
Use this form to give permission for a child to get medical care, even unaccompanied minors. It helps them get care more quickly and gives you peace of mind.
Living healthier with Medicare Advantage
Explore the benefits of Medicare Advantage plans. This guide has simple tips, care advice, contact information for resources and more, including screenings.
PHI Amendment – Infusion
Complete and return this form if you would like to amend the records Optum Infusion Pharmacy maintains about you if they are inaccurate or incomplete.