How to Fill Out and Submit the Optum Release of Information Form

The Optum release of information form is a written authorization that lets Optum share your protected health information with a person or organization you name. You can get the current form from Optum’s individual rights portal at individualrights.optum.com, complete it online or on paper, and return it by secure upload, fax, or mail.¹

Where to Get the Current Form

Optum posts the authorization on its individual rights portal. From the portal home page, open the Forms section and choose the Release of Information (ROI) authorization for disclosure of protected health information.¹ Two versions exist. The online form at memberforms.optum.com lets you type into the fields and submit electronically.² A printable PDF is also available if you’d rather sign by hand and fax or mail the paper copy.³

Pull a fresh copy each time. Optum updates its forms periodically, and an outdated version bookmarked from a past request can trigger a version mismatch and slow processing.

What to Have Ready Before You Start

Gather these details before you open the form so your request matches the right file:

Patient’s full legal name, date of birth, and mailing address.
Optum member ID from your insurance card. This is the primary identifier Optum uses to locate records.³
The recipient’s full name (or organization name), mailing address, and phone number.

Filling Out the Form

Scope of the Release

The scope section describes exactly what records Optum may share. Federal rules require the description to be “specific and meaningful,” so vague language like “all my records” can cause delays or partial denials.⁴ Narrow it by date range, type of record (medical, billing, or pharmacy), or a specific event such as a surgery or hospital stay. Tighter boundaries reduce the risk of releasing information you’d rather keep private.

You also need to state the purpose of the release. If you’re requesting the disclosure yourself, “at the request of the individual” satisfies the rule.⁴ A more specific purpose, such as “for use in a personal injury case,” is fine and can help the privacy office pull the right files.

Sensitive Record Categories

Some records carry extra protections and won’t be released unless you specifically authorize them. Substance use disorder treatment records fall under 42 CFR Part 2, which imposes stricter consent requirements than HIPAA does for most other health data.⁵ If your records include substance use treatment, the form typically asks you to check a box opting into that disclosure.

Psychotherapy notes have their own layer of protection. These are a therapist’s private session notes kept separate from your main chart, not diagnoses, prescriptions, or treatment summaries. A covered entity needs a distinct authorization to share them, even if you’ve signed a general release.⁴ A blanket “release everything” instruction won’t cover psychotherapy notes.⁶

Some states add separate protections for HIV/AIDS status and mental health treatment records, so the form may include additional checkboxes for those categories. Review every checkbox before signing. A sensitive category left unchecked stays sealed regardless of what you wrote in the scope section.

Signature, Date, and Expiration

Every authorization must carry your signature, the date you signed, and either an expiration date or a triggering event (for example, “when the lawsuit concludes”) after which it ends.⁴ If you leave the expiration blank, Optum applies a default that depends on the version you used. The PDF defaults to 36 months from the signature date.³ The online portal version caps authorizations at one year.² Some states set a shorter maximum. Pick the shortest window that actually serves your purpose; you can always sign a new authorization later.

Signing on Someone Else’s Behalf

If you’re signing as a personal representative, you need to attach documentation of your authority. For a living member who can’t sign, Optum accepts a durable power of attorney, guardianship papers, or conservatorship documents. For a deceased member, provide proof that you’re the executor or administrator of the estate.²

A general power of attorney isn’t always enough. If the document doesn’t explicitly grant healthcare authority, the privacy office may reject it, and a limited healthcare power of attorney only covers records within its stated scope. If legal documentation is already on file from a prior request, you don’t have to resubmit it, but tell the reviewer to look for it.¹

How to Submit the Completed Form

Optum accepts the authorization three ways:

Online upload through the individual rights portal at individualrights.optum.com. This is the most secure option and gives you an immediate confirmation.¹
Fax to 866-322-0051.⁷
Mail to ATTN Optum ROI Processing, 11000 Optum Circle, Mail Route MN103-0600, Eden Prairie, MN 55344.⁷

Always check the contact information printed on your specific form before sending. Optum uses different addresses for different product lines, and the fax number and address above come from the companion revocation form for the ROI processing center.

How Long It Takes and What It Costs

Federal rules give Optum up to 30 days after receiving your request to either provide the records or issue a written denial. A single 30-day extension is allowed for complex or archived requests, but only if Optum notifies you in writing with the reason and a new completion date.⁸ Straightforward requests often come back faster.

When you ask for electronic copies of records maintained electronically, HIPAA limits what you can be charged. Fees must be reasonable and cost-based, covering only labor to create the copy, supplies, and postage. Search and retrieval fees are prohibited. A flat fee of no more than $6.50 per request is allowed in lieu of calculating actual costs.⁹ Paper copies may cost more, and state laws sometimes set separate per-page rates. These HIPAA limits apply to patient-directed requests; attorney requests made under subpoena are generally governed by state fee schedules instead.

How to Revoke an Authorization

You can cancel a signed authorization at any time by submitting a written revocation. It takes effect when Optum receives it and does not undo disclosures that already happened while the authorization was active.⁴

Optum provides a dedicated Revocation of Authorization for Release of Health Information form on the individual rights portal. Send the completed revocation to the same ROI processing center by fax at 866-322-0051 or by mail to ATTN Optum ROI Processing, 11000 Optum Circle, Mail Route MN103-0600, Eden Prairie, MN 55344.⁷ If a legal representative signed the original authorization, the same representative (or one with equivalent authority) needs to sign the revocation and attach proof.

Why Forms Get Rejected

The privacy office reviews every form before releasing anything. These are the problems that trip people up most often:

Missing or mismatched signature. The form must be signed by the patient or a representative with attached proof of authority. An unsigned form gets sent back immediately.
No expiration date or event. Federal rules require one, and leaving the field blank on a version without an auto-default can stall the request.
Vague scope. A description that doesn’t identify the records in a specific and meaningful way gives the privacy office nothing to work with.
Incomplete recipient information. If Optum can’t identify who should receive the records or where to send them, the request can’t be fulfilled.
Outdated form version. Copies pulled from old bookmarks or third-party sites can trigger a version mismatch.

If Optum denies your request, it must provide a written explanation and tell you how to file a complaint with the Department of Health and Human Services if you believe the denial was wrong.⁸

1
Optum. Overview – Managing Your Healthcare Information
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Optum. Authorization for Release of Health Information
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Optum. Authorization for Release of Health Information Form
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eCFR. 45 CFR 164.508 – Uses and Disclosures for Which an Authorization Is Required
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eCFR. 42 CFR Part 2 – Confidentiality of Substance Use Disorder Patient Records
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U.S. Department of Health and Human Services. HIPAA Privacy Rule and Sharing Information Related to Mental Health
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Optum. Revocation of Authorization for Release of Health Information
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eCFR. 45 CFR 164.524 – Access of Individuals to Protected Health Information
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U.S. Department of Health and Human Services. Right to Access and Research