Patient forms and information
New patient form
Download and fill out the health assessment and insurance information form.
Member reimbursement claim form
Please use this form to ask to be reimbursed for care you paid for.
Protected health information (PHI) form
Fill out this form to get patient permission to share their protected health information (PHI) with an authorized representative.
Specialty financial assistance
Everyone should be able to access the treatments they need. We're here to help you find ways to access and afford your medication.
Specialty Pharmacy Texting Terms of Use
Notice of Privacy Practices
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.
Medicare Shared Savings Program
Learn more about the Optum California ACO and the high-quality care we offer Medicare patients.
Patient rights and responsibilities
This document explains your rights and responsibilities as an Optum patient.
Formulario de nuevo paciente
Descargue y llene el formulario de evaluación de salud e información de seguro aquí.
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.
"You don't look sick": Coping with the symptoms of MS
Multiple sclerosis (MS) symptoms aren’t easy to see. Optum helps patients with MS manage all their symptoms — seen and unseen.
Standard PHI authorization form Spanish
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.
Records request form
Download and fill out this form form to ask to send your records to another location.
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.
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.
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.
NWP medical record transfer forms
Find forms for requesting medical record transfers to and from providers.
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.
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.
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.
Personal representatives form Spanish
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.
New patient registration
Please complete these forms before your first visit with your doctor.
Specialty Pharmacy Community Residency
This 12-month post-graduate program offers a unique community practice environment to develop expertise in specialty pharmacy.
Patient rights and responsibilities
Please complete these forms before your first visit with your doctor.
Better financial health and improved operations
Improve cost optimization by controlling fixed costs, increasing efficiency and enabling organizational flexibility and agility.
Request to restrict use and disclosure of Protected Health Information (PHI)
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 or by another means
Complete and return this form if you would like to request confidential communications at an alternative address.
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.
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.
Advance beneficiary notice of noncoverage
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.
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.
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