Patient forms and information (41)
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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.
Alternative access standards
Learn more about alternative access standards for Medi-Cal members.
Appeal and grievance form
Use this form if you have an individual or family plan.
Appointment checklist
Make the most of your visit by being prepared.
Better financial health and improved operations
Improve cost optimization by controlling fixed costs, increasing efficiency and enabling organizational flexibility and agility.
Dr. Paula Hall colonoscopy packet
Use this paperwork if you are a new patient.
Financial policies
This will inform you of your financial responsibilities.
Interpreting services
Language assistance services are available to you at no cost.
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).
Medical release form — Indiana
Use this form to release medical and billing records.
Medical release form — Ohio
Use this form to release medical and billing records.
Medicare ACOs in Indiana
Find out more about the AHN Accountable Care Organization.
Medicare Shared Savings Program
Learn more about the Optum California ACO and the high-quality care we offer Medicare patients.
Member reimbursement claim form
Please use this form to ask to be reimbursed for care you paid for.
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.
New patient form - California
Download and fill out the personal information 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.
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.
Patient rights and responsibilities
Please complete these forms before your first visit with your doctor.
Patient rights and responsibilities
This document explains your rights and responsibilities as an Optum patient.
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.