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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.
Complete and return this form to give your permission to discuss and/or release your personal health information (PHI) to a person who is your Authorized Representative.
Complete and return this form if you would like to request restrictions on certain uses and disclosures of your PHI.
Complete and return this form if you would like to request confidential communications at an alternative address.
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.
Complete and return this form if you would like to receive an accounting of certain disclosures of PHI made by Optum Specialty Pharmacy.
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.
We may process some or all of your prescription(s) at any of our Optum Specialty Pharmacy locations. If you have questions, please call the phone number on your prescription label.