Medicare Part B Patient Consent Forms

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.

Advance Beneficiary Notice of Noncoverage (ABN)

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.