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.

Healing Arts Family Medicine (HAFM) record transfer form

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 records request

Use our secure online form to ask for a copy of your records.

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.

NWP medical record transfer forms

Find forms for requesting medical record transfers to and from providers.

Optum medical record transfer form

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.