Notices & Privacy

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.

We use this form to obtain your written consent to disclose your protected health information to someone designated by you. This request does not allow your designated person to make any of your treatment decisions or direct care decisions.

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.

Usamos este formulario para obtener su consentimiento por escrito para divulgar su información de salud protegida (protected health information, PHI) a alguien que usted haya designado. Esta solicitud no permite que esta persona tome decisiones sobre su tratamiento ni decisiones directas sobre la atención de la salud.

Use este formulario para dar su consentimiento para la divulgación de la información de salud protegida tanto verbal como escrita, que incluye su perfil o registro de recetas, a la persona que usted haya designado en el formulario.

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.

A Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. For Personal Representatives that have been legally appointed, the Personal Representative can complete this form and attach supporting legal documentation, such as a Power of Attorney that indicates full health care decision-making authority, guardianship documentation, etc.
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.

Un Representante Personal puede ser legalmente designado o nombrado por el miembro o el paciente para actuar en su nombre. En el caso de los Representantes Personales que hayan sido legalmente designados, pueden llenar este formulario y adjuntar documentación legal de respaldo, tales como un Poder que indique la autoridad total para tomar decisiones sobre la atención de la salud, documentación de la tutela, etc.

Use este formulario para identificar una persona que pueda tomar las decisiones sobre su atención de la salud, solicitar y divulgar su información de salud protegida, o ejercer sus derechos en su nombre.