In accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations
and rules (“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my
health and personal information to CooperSurgical, Inc. and it’s agent, Biologics, Inc. (and its aliates, and their respective
representatives, and agents [collectively, “Biologics”]) in furtherance of the below-stated authorized purposes. The “Paragard”
program is operated by Biologics on behalf of CooperSurgical, Inc.
I understand that the Paragard Program and Biologics will receive my health and personal information, which may include
my name, address, patient insurance identiﬁcation number, date of birth and other information necessary to obtain health
insurance beneﬁt veriﬁcation for the following purposes: (1) the administration of CooperSurgical’s Paragard Program;
(2) to conduct beneﬁt veriﬁcation determining insurance reimbursement and coverage of Paragard; (3) to contact me to
discuss any relevant co-pay; (4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare
provider; (7) to contact me by telephone in furtherance of conducting beneﬁts veriﬁcations investigations and/or specialty
pharmacy dispense; and (8) if I choose to self-pay for Paragard, to invoice me and to otherwise contact me to collect
payment for the Paragard unit.
By signing the following form, I understand:
1. Once my healthcare provider gives Biologics and the Paragard Program information about me based on this
Authorization, my medical and health information may be subject to redisclosure and is no longer protected by
federal privacy regulations.
I further understand and agree that Biologics and the Paragard Program may retain my medical and health information
as disclosed under this Authorization after this Authorization expires.
I also understand that in the event of an audit, and for purposes of such an audit, some information may also be disclosed
to CooperSurgical, Inc., the manufacturer of Paragard, or its aliates after this Authorization has expired, so long as
the audit is for a period of time when this Authorization was in eect.
2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not aect my ability
to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance beneﬁts.
3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider, health plan
and/or pharmacy that refers to (or with a copy of) this Authorization form, or to Biologics/the Paragard Program at 11800
Weston Parkway, Cary, NC 27513. I understand that if I revoke this Authorization, it will not aect prior disclosures made to
Biologics and any use of such information by Biologics in reliance of this Authorization. I understand that I have the right
to receive a copy of this Authorization.
4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.
Signature of Patient or Legal Personal Representative: Date: / /
Name of Patient or Legal Personal Representative:
(If Applicable) Description of Personal Representative’s Authority to Sign for Patient:
Paragard® is a registered trademark, and Paragard Beneﬁts Veriﬁcation
is a service mark of CooperSurgical, Inc.
Patient Authorization for Beneﬁts Veriﬁcation
© 2020 CooperSurgical, Inc.
C-US-PAR-000023 August 2020
Please see Important Safety Information and
Full Prescribing Information for Paragard at Paragard.com.