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Get Optumrx 10872 2020-2026
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How to fill out the OptumRx 10872 online
This guide provides step-by-step instructions for completing the OptumRx 10872 form. Designed to authorize the use and disclosure of your protected health information, this form simplifies your authorization process.
Follow the steps to efficiently fill out the OptumRx 10872 form online.
- Press the ‘Get Form’ button to access the document and load it into your editing interface.
- Begin with section one titled 'Member Information.' Fill in your last name, first name, middle initial, mailing address, city, apartment number (if applicable), state, ZIP code, member ID number, and date of birth in the format mm/dd/yyyy.
- In section two, provide your phone number with area code. Then, specify the information of your authorized representative(s) by filling out their name, phone number, mailing address, and relationship to you. Complete these details for both authorized representative #1 and #2.
- In section three, describe the specific information you authorize to be used or disclosed. If you leave this blank, all of your protected health information will be disclosed.
- For section four, indicate the purpose of the disclosure. This should assist in receiving health plan benefits and making payments, along with any additional reasons you may wish to include.
- When filling out section five, note the expiration of the authorization. Provide the expiration date or be aware that it is valid for sixty months from your signature date unless otherwise specified.
- Section six requires your signature and the date of signing. If a legal representative signs on your behalf, include necessary documentation and their information.
- Finally, save your changes. You may either download the completed form, print it out, or share it as needed.
Complete your forms online today for a hassle-free experience!
Setting up your OptumRx 10872 account is a quick process. Start by visiting their homepage and clicking on 'Register.' You’ll need to provide basic personal information, including your member ID, and create a password. Once your account is established, you can access a variety of services, including managing prescriptions.
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