BAuthorizationb to Share Personal bInformation Formb - UnitedHealthcare 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member Information section. Enter your Member ID number, date of birth, first name, middle initial, last name, and permanent address including city, state, and ZIP code.
3. Provide your daytime and evening telephone numbers. Optionally, include your email address for updates.
4. In the 'Who Do You Want to Share Your Information With?' section, enter the name and optional address of the person or organization you wish to authorize.
5. Sign and date the form in the 'Your Permission' section. If applicable, complete the Legal Representative Information if someone is signing on your behalf.
6. Finally, send the completed form via mail or fax to UnitedHealthcare at the provided addresses.

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