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Mental Health / Employee Asssistance Programs (EAP)

The following forms will help you manage your healthcare information for United Behavioral Health, mental health, substance abuse, Life Solutions, and Employee Assistance Program (EAP). UnitedHealthcare behavioral health benefits are managed by Optum.

What you’ll need:

  • A printer to print the form,
  • In some cases, your health plan ID card, and
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number of where to return it.

What would you like to do with the healthcare information we have about you?

Click herePDF Opens in a new window or tab for a form you can download and return to request a copy of your healthcare information that we maintain.


Click herePDF Opens in a new window or tab for a form you can download and return to request a change to your healthcare information that we maintain.


Click herePDF Opens in a new window or tab for a form you can download and return to receive correspondence at a confidential address. If this is an urgent request, please contact customer service at the phone number on the back of your health plan ID card to make a verbal request.


Click herePDF Opens in a new window or tab for a form you can download and return to change an existing confidential communication address.


Click herePDF Opens in a new window or tab for a form you can download and return to limit who your healthcare information is released to or how it is used. We use and disclose member level information only as necessary to provide services to our members and as permitted and required by law. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.

  • To complete the form electronically:
    • Go back to the "Managing your health" section of Live and Work WellOpens in a new window or tab to locate the hyperlink to the Release of Information form. This link can be located under “Find a Resource” and then “Forms.”
    • Follow instructions for electronic submission.

Click herePDF Opens in a new window or tab for a form you can download and return to stop sharing your healthcare information with someone else.


  • To complete the form electronically:
    • Go back to the "Managing your health" section of Live and Work WellOpens in a new window or tab to locate the hyperlink to the Release of Information form. This link can be located under “Find a Resource” and then “Forms.”
    • Follow instructions for electronic submission.

Click herePDF Opens in a new window or tab for a form you can download and return to obtain a list of who your information has been disclosed to for purposes outside of treatment, payment, or healthcare operations.


  • Via email at privacy@optum.comOpens in a new window or tab.
  • Via mail at:
    Optum
    Privacy Administrator
    MN101-E013
    11000 Optum Circle
    Eden Prairie, MN 55344
  • You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

  • If you are enrolled in an insured plan offered by UnitedHealthcare, click hereOpens in a new window or tab to obtain a copy of the NPP outlining how your healthcare information may be used and/or disclosed.
  • If you are enrolled in an insured plan offered by UnitedHealthcare Community & State, click hereOpens in a new window or tab to obtain a copy of the NPP outlining how your healthcare information may be used and/or disclosed.
  • If you are enrolled in a different UnitedHealthcare plan that is not listed above, please contact your plan for a copy of its HIPAA NPP.

If you are unable to find the form you need or have questions, please contact the phone number on the back of your health plan ID card.