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

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Provide your last name, first name, middle initial, mailing address, date of birth, gender, phone number, and ZIP code. Ensure all information is current for accuracy.
3. In the Authorized Representative’s Information section, list the names and contact details of individuals you authorize to access your protected health information (PHI). Include their relationship to you.
4. Describe the specific information you wish to disclose in the Description of Information section. If left blank, all PHI will be authorized for disclosure.
5. State the Purpose of Disclosure clearly. This helps clarify why you are granting access to your PHI.
6. Review the Expiration and Revocation section. Indicate when this authorization should expire or leave it blank for a default of twelve months.
7. Finally, sign and date the Authorization and Signature section. If applicable, have a witness sign as well.
8. Submit the completed form by mailing it to Optum or faxing it as indicated at the bottom of the form.

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