Optum and WellMed contact form
Optum and WellMed have joined forces to better serve Medicare Advantage members in Florida. Complete this short form so your clients can get priority appointment scheduling with their Optum or WellMed primary care provider.
Please read to your client before completing
By allowing me to complete this contact form, you authorize me, (broker name) to disclose your name and contact information to Optum (state) or WellMed to establish your future patient/doctor relationship with an Optum or WellMed provider.
You understand and agree that:
- This authorization to provide us this information is voluntary;
- You may not be denied treatment, payment for health care services, or enrollment or eligibility for health care benefits if you do not agree to this disclosure;
- Your name, primary care provider, name, address, may be subject to redisclosure by the recipient, and if the recipient is not a health plan or health care provider, the information may no longer be protected by the federal privacy regulations;
- This authorization will expire one year from today (event or time, once they have their first visit with their doctor);
- You may revoke this authorization at any time by notifying me (broker). However, the revocation will not have an effect on any actions taken prior to the date your revocation is received and processed.
By completing this form and providing your email, you acknowledge you will receive a confirmation email that may include patient health information, such as PCP name, and will be sent unencrypted.
There is a risk of interception or disclosure of the contents of these emails.
Please complete the below information.