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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.