Forms and resources for patients
Financial assistance form
Apply for financial assistance to manage your health care costs. Get the support you need and submit your form today.
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.
GoLYTELY procedure preparation
These instructions are for patients who have been prescribed GoLYTELY ahead of their scheduled colonoscopy.
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.
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.
Patient rights and responsibilities — Arizona
Please complete these forms before your first visit with your doctor.
24 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Medical record release authorization – Nevada
We use this form to obtain your written authorization to disclose your PHI to someone designated by 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.
MiraLAX procedure preparation
These instructions are for patients who have been prescribed MiraLAX ahead of their scheduled colonoscopy.
18 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
6 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Optum Medical Care release of health information — New York
Request medical records using a paper form.
ADHD pediatric form
Use this form if your child is being evaluated for ADHD or has already been diagnosed and is receiving treatment.
Notice of privacy practices — Washington
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 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.
Acute illness pediatric form
This is the form you need if your child is experiencing symptoms of an acute illness requiring medical attention.
Medical record release authorization – Washington
Safely share your medical records. Be confident knowing your health information is being sent according to your wishes.
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 — New Jersey
Request medical records using a paper form.
30 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
15 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
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.
2 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
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.
Medicare Shared Savings Program
Learn more about the Optum California ACO and the high-quality care we offer Medicare patients.
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.
Medical release form – Ohio
Use this form to request medical and billing records from American Health Network and Optum–Ohio.
Medical record release authorization – Arizona
We use this form to obtain your written authorization to disclose your PHI to someone designated by 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.
4 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
2 week well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Optum Frontier Therapies request to amend PHI form
Use this form to amend Protected Health Information (PHI).
3 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Asthma pediatric form
Use this form if your child is having difficulty breathing due to asthma and needs medical attention.
Medical release form – Indiana
Use this form to request medical and billing records from American Health Network and Optum–Indiana.
Medical record release authorization – Colorado
We use this form to obtain your written authorization to disclose your PHI to someone designated by you.
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.
Member reimbursement claim form
Please use this form to ask to be reimbursed for care you paid for.
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 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.
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 Frontier Therapies Patient Regulatory Packet
This packet has important information about our pharmacy.
Optum Frontier Therapies Sucraid letter of medical necessity school/work
Use this form to submit to school or work to show medical need for Sucraid® medication.
Optum Frontier Therapies authorization to use and disclose PHI form
Use this form to authorize the use and disclosure of Protected Health Information (PHI).
Patient rights and responsibilities — National
This document explains your rights and responsibilities as an Optum patient.
Notice of privacy practices — Pharmacies
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.
Consent for gastrointestinal endoscopy
Authorizes the performance of a gastrointestinal endoscopic procedure after the patient has been informed of the purpose, risks, benefits and alternatives.
12 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Optum Frontier Therapies patient acknowledgement and consent to treatment
This form includes consent for treatment as well as acknowledgement of the following: assignment of insurance benefits acknowledgement, payment of services rendered, receipt of notice of privacy practices, and product warranty/replacement information.
Concussion pediatrics form
Download and fill out this form if your child has experienced a head injury and requires medical attention.
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.
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.
5 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Optum East MSSP accountable care organization
Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) help people with Traditional Medicare receive high-quality care.
Optum Frontier Therapies Sucraid PAP enrollment form
Use this form to enroll in Sucraid®'s Patient Assistance Program.
Newborn pediatric form
Download and fill out the questions on this form when you are bringing in your newborn baby for a checkup.
Radiology PHI authorization form – Nevada
We use this form to obtain your written authorization to disclose your PHI to someone designated by you.
7–10 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
11–14 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Ambulatory surgery centers patient rights and responsibilities
Outlines the patient’s rights and responsibilities when receiving care at an ambulatory surgery center, including safety, privacy, participation in care and conduct expectations.
Optum Frontier Therapies Sucraid letter of medical necessity travel
Use this form to carry with you when you need to travel with Sucraid® medication.
4 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
15 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Optum Medical Care credit card authorization form
A credit card authorization form is available and may be reviewed during your visit.
1 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
EGD procedure preparation
These instructions are for patients scheduled to undergo the minimally-invasive procedure, EGD, to examine their gastrointestinal tract (stomach, esophagus, etc.).
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.
Veterans Benefits Administration (VBA) Medical Disability Examinations (MDE) inquiry form
Use this form to submit your inquiry regarding a Veterans Benefits Administration Medical Disability Examination.
9 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
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 record release authorization – New Mexico
We use this form to obtain your written authorization to disclose your PHI to someone designated by you.
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.
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.
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.
Optum Frontier Therapies Sucraid PAP application form
Use this form to apply for Sucraid®'s Patient Assistance Program.
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.
Optum Frontier Therapies request for confidential communication privacy form
Use this form to request confidential communications at an alternative address or by another means.
Surprise billing protection — National
Know your rights and protections against surprise billing.
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Surprise billing protection — Washington
Learn more about your rights and protections against receiving surprise medical billing from providers in the state of Washington.
Optum Frontier Therapies request for access to PHI form
Use this form to request access to Protected Health Information (PHI).
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.
Optum Frontier Therapies request for record of non-routine PHI disclosures form
Use this form to request records of non-routine disclosure of Protected Health Information (PHI).
Optum Specialty Pharmacy request to restrict use and disclosure of PHI form
Use this form to restrict use and disclosure of Protected Health Information (PHI).
Sleep study patient instructions
These instructions are for patients that have an overnight sleep study scheduled at the Optum Sleep Center.
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.
6 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
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.
Optum Frontier Therapies request to restrict use and disclosure of PHI form
Use this form to restrict use and disclosure of Protected Health Information (PHI).
Optum Frontier Therapies Manufacturer PHI Auth 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.
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.
Alternative access standards
Learn more about alternative access standards for Medi-Cal members.