Xolair copay card3/4/2023 ![]() ![]() I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen at 1-84 or by writing to The Crossings at Jefferson Park, 200 Jefferson Park, Whippany, NJ 07981. I understand and agree that by signing below, I am authorizing those who rely on this Authorization to release my personal health information for the earlier of five (5) years or until my participation in the program ends through my cancellation, unless a shorter time period is required by state law. I also understand I am authorizing my personal information, including my personal health information, to be used for the purposes described above. I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to only release it to Amgen employees, as well as to its contractors and business partners, who are performing the services set forth in this Authorization. I understand that certain of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Amgen in exchange for disclosing my personal health information and/or for using my information to contact me with communications about Amgen products which have been prescribed to me (for example medication reminder programs) and other patient support services.Įxpiration, Right to Obtain a Copy and Right to Cancel I authorize my Health Care Providers to disclose my personal health information to Amgen, and between themselves, as necessary, but only for the purposes stated above in this Authorization. ![]() This may include select information from or about my medical history and general health, my health care plan benefits, payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment. I understand that my personal health information may include any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company, laboratory and/or their contractor (“Health Care Provider”). In order for Amgen to provide me with the services and/or programs described above, Amgen needs to collect and use my personal information, including my personal health information. To improve, develop, and evaluate products, services, materials and programs related to my condition or treatment.To provide me with informational and promotional materials relating to Amgen products and services, and/or my condition or treatment and/or.To contact, with my permission, my doctor and the rest of my health care team and share with them my health information that may be useful for my care.To operate, administer, enroll me in, and/or continue my participation in Amgen’s Corlanor ® Copay program or any other Amgen-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs, reimbursement assistance programs, drug coverage verification, nurse educator services, adherence program and disease management support).I authorize Amgen and its contractors and business partners (“Amgen”) to use and/or disclose my personal information, including my personal health information, only for the following purposes: ![]() ![]() Uses and Disclosure of Personal Information ![]()
0 Comments
Leave a Reply.AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |