BriovaRx Privacy Forms

Standard PHI Authorization Form

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.

Request to Restrict Use and Disclosure of Protected Health Information

Complete and return this form if you would like to request restrictions on certain uses and disclosures of your PHI.

Request for Confidential Communications at an Alternative Address

Complete and return this form if you would like to request confidential communications at an alternative address.

Request for Access to Protected Health Information

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.

Request for an Accounting of Non-Routine Disclosures of Protected Health Information

Complete and return this form if you would like to receive an accounting of certain disclosures of PHI made by BriovaRx.

Request to Amend Protected Health Information

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.

HIV-AIDS Medication Exemption PDF Form

HIV-AIDS Medication Exemption PDF Interactive Form

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

Fax: 1-855-873-2378

Email:BriovaRxContactUs@BriovaRx.com