Get Optumrx 10872 2018-2025

The OptumRx 10872 form is designed to grant permission for the use and disclosure of your protected health information (PHI). This guide will provide step-by-step instructions on how to fill out the form accurately and efficiently, ensuring your information is handled properly.

Follow the steps to complete the OptumRx 10872 form.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. Begin filling out Section 1 with your patient information. Provide your last name, middle initial, first name, mailing address, apartment number (if applicable), city, state, date of birth in the format mm/dd/yyyy, gender (select either Male or Female), ZIP code, date of injury in mm/dd/yyyy format, and phone number with area code.
3. In Section 2, list the information of your authorized representatives. You need to provide their names, phone numbers with area codes, mailing addresses, city, apartment numbers (if applicable), state, ZIP code, and their relationship to you. Fill this for each authorized representative you wish to include.
4. Section 3 requires you to describe the information you are authorizing to be disclosed. If you want to grant permission for all PHI including your patient profile and records, you may leave this section blank.
5. In Section 4, specify the purpose of the information disclosure. This can include assisting in receiving benefits or payments for benefits. Clearly state any additional purposes as needed.
6. Section 5 discusses expiration and revocation. You must note whether you want the authorization to expire at the termination of your claim or set an expiration date of your choosing. If no date is provided, it will be valid for twelve months from the date of your signature.
7. In Section 6, sign the form to authorize the disclosure. Make sure to include the date you are signing. If applicable, have a witness sign and date the form as well. If you are signing on behalf of someone else, include the legal representative’s name, mailing address, and relationship to the patient.
8. Finally, in Section 7, send the completed form by mailing it to Optum, Attn: Medical Records, 250 Progressive Way, Westerville, OH 43082 or fax it to 1-614-212-8008. Retain a copy of the form for your records.

Start filling out your OptumRx 10872 form online now for a smoother healthcare experience.