Notices & Privacy

Standard PHI Authorization Form

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.

Request to Restrict Use and Disclosure of Protected Health Information

Complete and return this form if you would like to request restrictions on certain uses and disclosures of your PHI.

Request for Confidential Communications at an Alternative Address 

Complete and return this form if you would like to request confidential communications at an alternative address.

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.

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.

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.

Pharmacy Fulfillment Notice

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.