BriovaRx Forms and Notices
BriovaRx Privacy Forms
Complete and return this form to give your permission to discuss and/or release your personal health information (PHI) to a person who is your Authorized Representative.
Complete and return this form if you would like to request restrictions on certain uses and disclosures of your PHI.
Complete and return this form if you would like to request confidential communications at an alternative address.
Complete and return this form if you would like to access and inspect the information BriovaRx maintains and uses to make decisions about the services we provide you.
Complete and return this form if you would like to receive an accounting of certain disclosures of PHI made by BriovaRx.
Complete and return this form if you would like to amend the records BriovaRx maintains about you if they are inaccurate or incomplete.
HIV Exemption Program *
Patients who are receiving treatment for HIV infection may be able to fill their specialty medications at an in-network pharmacy of their choice.
Am I eligible for an exemption?
Complete and return this form if you do not want to have your HIV treatment related specialty medications shipped to you by BriovaRx for one or more of the following reasons: privacy concerns, delivery concerns, or you are unable to effectively discuss your condition over the phone due to an HIV-related neurocognitive disorder or the significant HIV-related impairment that is being monitored or treated.
Please complete, sign and date this form, and provide your name, address, telephone number, and member identification number where indicated and submit to OptumRx through one of the below options. Or, you may call us at 1-866-803-8570.
Mail:OptumRx, P.O. Box 2508, Mission, KS 66201
* to the extent applicable based on plan benefit
Medicare Part B Patient Consent Forms
Form that designates BriovaRx as an approved provider for a member's Medicare Part B eligible medications. Please complete and return the form to the requesting department.
Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to BriovaRx. Please complete and return the form to the requesting department.
Pharmacy Fulfillment Notice
We may process some or all of your prescription(s) at any of our BriovaRx specialty pharmacy locations. If you have questions, please call the phone number on your prescription label.
A member of our team can help answer any questions you have. Just call us toll-free at
To learn about our key areas of care, select a condition.