Get Authorization To Use And Disclose ... - Optumrx

Filling out the Authorization to Use and Disclose Protected Health Information form is an important step in allowing designated representatives access to your health information. This guide provides a straightforward approach to completing the form correctly and efficiently.

Follow the steps to complete your authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by filling out the member information section. Provide your last name, middle initial, first name, mailing street address, city, apartment number (if applicable), state, ZIP code, member ID number, and date of birth (in mm/dd/yyyy format). This information is essential for identifying your record.
3. Next, enter your phone number with area code in the designated field. Ensure that this number can be used for any necessary communications regarding this authorization.
4. In the authorized representatives section, list the individual(s) or organization(s) you permit to access your protected health information (PHI). For each representative, provide the name, phone number with area code, mailing street address, city, apartment number (if applicable), state, ZIP code, and their relationship to you.
5. In the description of information to use or disclose section, specify the information that you authorize to be disclosed. If you leave this section blank, all of your PHI will be authorized for release.
6. Document the purpose of the disclosure in the relevant section. This may include assisting you in receiving health plan benefits or any other specified reasons.
7. Indicate the expiration date of the authorization. If no date is provided, the authorization will be valid for 60 months from the date of your signature.
8. Sign and date the authorization in the provided spaces. If a witness is required, have them sign and date in the relevant area. If you are signing on behalf of another, ensure legal documentation is attached.
9. Once completed, save your changes. You can then download, print, or share the form as required.

Proceed to fill out your form online to ensure your health information is appropriately authorized for disclosure.