Authorization for release of protected health information (ROI)

Member information (please provide current information)

People or Organizations who will receive this information

Last Name

Name

Phone Number with Area Code

Mailing Street Address

City

Relationship to Member

First Name

State

ZIP

Apt. #

Mailing Street Address

City

Date of Birth (mm

/dd/yyyy)

Member ID Number

Phone Number with Area Code

Authorization for release of

protected health information (ROI)

Optum uses this form to get your permission to disclose your personal health information, which is known as

Protected Health Information (PHI) under the law. By completing and signing this form, you agree that

Optum and its related businesses may disclose information to the people or organizations you provide

below. By Optum’s related businesses, we mean its subsidiaries and affiliates.

220585-062022

I agree that Optum and its related businesses may disclose my PHI to the people or organizations named below. I

understand that health care providers, health plans, and others are required to protect my PHI under federal law. If a

person or organization is not a health care provider, health plan, or another party required to protect my PHI, it could

be discussed or released without my permission.

This form should not be used to request a copy of your records; please see Instructions for information to submit a

Request for Records.

Person or Organization #1

Relationship to Member

Person or Organization #2

[System Platform]

Please print legibly

Description of information to use or disclose

Purpose of disclosure

Please describe the information covered by this authorization.

I understand that by leaving this section blank, I am authorizing the disclosure of all of my PHI, including my health

information. This may include medical, pharmacy, dental, vision, mental health, HIV/AIDS, psychotherapy, reproductive,

communicable disease and health care program information. I also intend this disclosure to include all substance use

disorder records (if any).

Description:

The purpose of this authorization is to disclose my health information held by Optum at my request. If there are other

purposes or reasons for this authorization, please provide them below.

Purpose:

Expiration and revocation

This authorization will be active for 3 years (36 months) from the date of my signature below or on the date I have

indicated below or as required by law. If you are a resident of Maine, Maryland, Minnesota, or Montana the expiration date

cannot exceed the following length of time:

• Maine: 30 months

• Maryland: 12 months

• Minnesota: 12 months

• Montana: 30 months

This authorization will expire on (insert date): _______________________________.

I have the right to end this authorization at any time by notifying Optum in writing at the address listed below. I

understand that ending this authorization will not affect Optum’s disclosures or uses of PHI by Optum before receiving

my notice.

Please keep a copy of this form for your records. You also have the right to receive a copy of this authorization.

For Authorized Representatives Who Are Receiving Substance Use Disorder Information

This information may have been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from

making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference

to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written

consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2.

Please mail the completed form to:

Optum

Attn: ROI Processing

PO BOX 1495

Shawnee Mission, KS 66222

or fax to 1-866-322-0051

Authorization and signature of individual or individual’s legal representative

I have read and understand this Authorization for Release of Protected Health Information. I understand that by

signing this form I am voluntarily giving my permission for Optum to use and disclose my PHI to the people or

organizations named in Section 2. Optum will not deny treatment, payment, enrollment, or eligibility for health care

benefits if I do not sign this authorization.

Member Signature Date

Name and relationship if signing on behalf of a minor child:

Legal Representative’s Name Date

Apt. #Mailing Street Address

City State ZIP

Relationship to Member

If on behalf of a minor child, we may require additional information.

If this authorization is signed on the member’s behalf by someone other than the parent or guardian, as such their

legal or court appointed representative, please attach documentation of the legal authorization and complete the

following. This can include a power of attorney or a court order. Do not send your original legal documents. Only send

a copy of these documents as we do not have the ability to return your original documents.

68303B-052023

1. Demographical Information Fill in your name, date of birth, address information and your

subscriber ID. This information is required for identification

and authentication purposes.

2. People or Organizations who will receive

this information

Write the name and address of the individual(s) that

you authorize Optum to disclose information to

regarding your care.

This form should not be used to request a copy of your

records; it is intended to allow us to share protected health

information (PHI) with the individual you have authorized. If

you or your legal representative would like to request a copy

of your records, please complete the “Request for Access to

Protected Health Information” form, which can be obtained

through the instructions below:

• Go to https://individualrights.optum.com/. Navigate to

Forms, select the type of healthcare information needed

and submit an electronic request using the link under

“Get it,” or

• Call customer service at the telephone number located

on your health plan ID card and ask that we mail or email

a “Request for Access to Protected Health Information”

form to you. The form will provide further instructions for

completion and where to send it to obtain your records.

Please note: You must list someone other than yourself

as an authorized individual. If you list yourself as the

authorized individual, your form will be rejected.

3. Description of Information to Use or Disclose Leave this section blank if you would like all information to

be disclosed to your representative. If you would not like all

information to be disclosed to your representative please

write on the line what information you would like disclosed.

4. Purpose of Disclosure The purpose of this authorization is to disclose your health

information held by Optum at your request. If there are oth-

er purposes or reasons for this authorization, please write

the reason on the line provided.

5. Expiration and revocation

This authorization will be active for 3 years (36 months)

from the date of your signature in section 6 or on the date

you have indicated in this section. If you are a resident of

Maine, Maryland, Minnesota, or Montana the expiration date

cannot exceed the following length of time:

Maine: 30 months

Maryland: 12 months

Minnesota: 12 months

Montana: 30 months

6. Authorization and signature of individual or

individual’s legal representative

Member must sign and date the form unless the form is

accompanied by a Legal document that gives authority for

someone to sign and date on member’s behalf.

Please do not send original legal document, only send a

copy, as we are unable to return document.

Instructions for Completing

Authorization for Release of Information