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Please read to your client or have them read before completing
The purpose of this form is to pass your personal information to Optum or a group that is part of Optum. They will use this information to call you to schedule an appointment with a doctor who belongs to Optum or a group that is part of Optum. By letting me, (broker name), complete this form, you are giving your OK for me give your information to Optum (state) or a group that is part of Optum Care.

You understand and agree that:

  • You are giving your information willingly (you are not being forced to give it).
  • If you decide that you don’t want to complete this form, it won’t change how Optum offers care or how you qualify for care.
  • If your information is given to a person or organization who is not a health plan or health care provider, your information may no longer be protected by federal privacy laws. That person or organization could share your information with another person or organization.
  • This permission will expire (end) once you have your first visit with your doctor. 
  • You may cancel this permission by telling me (broker). This will stop us from sharing your information going forward. But it can’t cancel any information that’s already been shared.


By agreeing to this form and sharing your email address, you also agree that we will send you an email to confirm. This email may include your patient health information, such as a primary care provider’s name. The email:

  • Will be sent unencrypted (it won’t be coded to keep others from reading it)
  • Could be read by someone else or taken by someone and shared with someone else 

Please complete the below information. 

Florida Agents: this service is only offered for employed (wholly owned) Optum and WellMed clinics.