Your health plan provides members with access to a website with exclusive, members-only pricing and discounts on health and wellness related products and services. There is no additional cost to access this website, but it does require you to authorize your health plan to share your information with myOptumHealthStore, to enable myOptumHealthStore to offer you products or services relevant to your health.

Consent

By signing below, I authorize my health plan to disclose my health and demographic information to myOptumHealthStore to offer and market products and services to me.

I understand this authorization is voluntary and may be revoked at any time by mailing a written request to OptumHealth Customer Service P.O. Box 2006 Neenah, WI 54957,

and that refusing to grant permission will have no effect on my ability to obtain insurance or insurance benefits.

I also understand that if I choose not to provide this authorization now I will not be able to access the member discounts provided on the myOptumHealthStore website.

This authorization is valid for one year only, and at expiration I may be requested to re-authorize to continue my access to member discounts. I can request a copy of this authorization by sending a written request to OptumHealth Customer Service P.O. Box 2006 Neenah, WI 54957.

I understand that once my information has been disclosed to myOptumHealthStore that federal and state privacy laws will no longer protect it; however myOptumHealthStore agrees to protect my information by using it for the purpose of providing me with offers for goods and services that support a healthy lifestyle.

I understand that my health plan and its business associates and their affiliates may receive direct or indirect remuneration from myOptumHealthStore and its partners as a result of my accessing these member discounts.