©2019 Gilead Sciences, Inc. All rights reserved. ADMC0469 08/19
By checking this box, I agree to receive marketing information, oers and educational materials related to my medical condition, treatment, and/or my
prescription medication, including the customer relationship marketing program.
SIGNATURE of PATIENT or PATIENT’S REPRESENTATIVE (REQUIRED): DATE:
Patient Representative’s Name (if signing for the patient):
Patient Representative’s Relationship to Patient:
FAX COMPLETED FORM TO ADVANCING ACCESS AT 1-800-216-6857
8. PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION REQUIRED
I understand that I must complete this enrollment form before I can receive assistance through Gilead Sciences, Inc.’s
Advancing Access (“Program”) and the Patient Assistance Program/Medication Assistance Program (“PAP/MAP”). As part
of this process, Gilead and its agents and contractors (collectively, “Gilead”) will need to obtain, review, use and disclose
my personal and medical information as described below. I hereby authorize my healthcare providers and health plans to
disclose my personal and medical information as described below to Gilead in connection with the Program and/or the
PAP/MAP, all in accordance with this authorization, and I authorize Gilead to use and disclose the information in accordance
with the authorization.
Information to Be Disclosed: Personal health information (“PHI”), including information about me (for example, my
name, mailing address, nancial information, and insurance information), my past, current and future medical condition
(including information about my HIV-related status or treatment with this prescription medication and related medical
condition), and all information provided on this enrollment form.
Persons Authorized to Disclose My Information: My healthcare providers, including any pharmacy that lls my prescription
medication, and any health plans or programs that provide me healthcare benets. I understand that my pharmacy
providers may receive remuneration for disclosing my PHI pursuant to this authorization.
Persons to Which My Information May Be Disclosed: Gilead, including the third party administrator responsible for the
administration of the Program and the PAP/MAP.
Purposes for Which the Disclosures Are to Be Made: Disclosures of PHI may be made to Gilead so that Gilead may use and
disclose the PHI for purposes of: 1) completing the enrollment process and verifying my enrollment form; 2) establishing
my eligibility for benets from my health plan or other programs; 3) providing nancial assistance, support, and referral
support, and communicating with my healthcare providers, including, but not limited to, facilitating the provision of my
prescription medication to me; 4) contacting me to evaluate the effectiveness of the Program and/or the PAP/MAP; 5) for
Gilead’s internal business purposes, including quality control and support enhancing surveys; and 6) to send me marketing
information, offers, and educational materials related to my treatment and/or my prescription medication, including the
customer relationship marketing program (this use of my personal information is optional and by checking the box under
the signatures below, I may opt in).
I understand that once my PHI has been disclosed hereunder, federal privacy law may no longer restrict its use or disclosure.
I understand further that I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benets or
ability to obtain treatment from my healthcare providers will not change, but I will not have access to the support offered
by Program and/or the PAP/MAP. I also understand that I may cancel this authorization at any time by notifying Gilead in
writing at Advancing Access, PO Box 13185, La Jolla, CA 92039-3185. If I cancel, Gilead will stop using this authorization
to obtain, use or disclose my PHI after the cancellation date, but the cancellation will not affect uses or disclosures of any
PHI that have already been made pursuant to this authorization before the cancellation date. I am entitled to a copy of this
signed authorization, which expires the earlier of two (2) years from the date it is signed by me or other time period required
under the laws of the state in which I reside.
ADVANCING ACCESS ENROLLMENT FORM PHONE: 18002262056 FAX: 18002166857 PAGE 2 OF 3
PATIENT NAME: __________________________________________________________________ DATE OF BIRTH: __________________________ ___________________________