Get Optumrx 10872 2016-2025

Filling out the OptumRx 10872 form is a critical step for providing permission for the use and disclosure of your protected health information. This guide will walk you through each section of the form, ensuring that you understand the requirements and process.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and access it in your editor.
2. Begin by entering your member information in Section 1. This includes your last name, first name, middle initial, mailing address, city, apartment number (if applicable), state, ZIP code, member ID number, and date of birth. Ensure all details are current and accurately reflect your information.
3. In Section 2, provide your phone number with area code, and enter the information for your authorized representatives. List their names, phone numbers, mailing addresses, state, ZIP codes, and relationship to you. You can include up to two representatives.
4. Section 3 requires you to describe the specific information you wish to be disclosed. If you leave this section blank, you will be authorizing the disclosure of all of your protected health information, including patient profile and prescription records.
5. In Section 4, specify the purpose of the disclosure. This is often to assist in receiving health plan benefits and making payments. You may add any other purposes if relevant.
6. Section 5 addresses the expiration and revocation of this authorization. You must state an expiration date, or the authorization will be valid for sixty months from the date you sign. Understand your rights to revoke this authorization in writing if needed.
7. In Section 6, provide your signature, date, and if applicable, the witness signature. If a legal representative signs on your behalf, make sure to attach the required documentation.
8. Finalize the process by mailing the completed form to OptumRx at the provided address, or faxing it to the listed number. Ensure you keep a copy for your records.

Start filling out your OptumRx 10872 form online today for a smoother health information management experience.