OptumRx, on behalf of itself and affiliated companies, uses this form to get your permission to use 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your member information in Section 1. Provide your last name, first name, mailing address, member ID number, and date of birth.
3. In Section 2, list the authorized representatives who will have access to your protected health information (PHI). Include their names, phone numbers, addresses, and relationship to you.
4. Section 3 requires you to describe the specific information you are authorizing for disclosure. If left blank, all PHI will be disclosed.
5. In Section 4, state the purpose of this authorization. This could include receiving health plan benefits or other reasons.
6. Section 5 allows you to specify an expiration date for this authorization. If not provided, it will remain valid for sixty months from your signature date.
7. Finally, sign and date the form in Section 6. If applicable, have a witness sign as well. Ensure any legal representative documentation is attached if necessary.
8. Mail or fax the completed form as instructed at the bottom of the document.

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