Authorization for Release of Health Information

Fill out this form to give UnitedHealthcare and its affiliates permission to share your personal information with others based on your selections below. This could include family members, doctors, etc. This information could include protected health information (PHI).

NOTICE: Your health information is protected under federal law. Any person who submits this form with any false or misleading information could face civil and criminal penalties.

Estimate time to complete form:
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5-10 minutes

This form is for:

  • Members or their legal representatives looking to authorize others to be able to access their personal health information.

This form is NOT for:

  • Submitting claims
  • Submitting appeals

If you want to submit a claim, go here .

If you want to submit an appeal, go here .

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