Fillable Informaon and consent for the paent support program (Desjardins Insurace)

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Informaon and consent for the paent support program (Desjardins Insurace)

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Informaon and consent for the paent
support program for specialty drugs
16078E (2020-10)
INFORMATION
The prescripon drug that is the object of your request is part of our paent support program. Designed to help you
beer manage your medical condion, this program provides you with many benets such as access to professional
support from a team of pharmacists. For more informaon, see the Prior Authorizaon Drugs and the Paent Support
Program brochure, available at www.desjardinslifeinsurance.com/PAD.
If your contract includes the program, you may be required to parcipate.
A healthcare professional from the provider selected by Desjardins Insurance will contact you to let you know the
status of your request, to explain how the program works and to direct you to a preferred pharmacy. That professional
may also contact your aending physician to get any missing informaon. The informaon obtained as a result of this
prior authorizaon request will be sent to the third party and used to process your request. This is why your signature
is required.
IMPORTANT
As part of the paent support program, you will be reimbursed for your specialty drug only if you purchase it
through the preferred pharmacy network.
CONSENT TO DISCLOSE TO A THIRD PARTY
For the sole purpose of the paent support program, I authorize Desjardins Insurance to disclose to the third party
personal informaon about me, especially my medical informaon, that is needed for the program. I understand that
the third party may share this informaon with my doctors, pharmacists and other healthcare professionals as part
of this program.
This consent also applies to the disclosure of personal informaon concerning my dependents, insofar as this request
involves them.
Please ll out this page only if you live outside Quebec.
This consent is an integral part of the aached Prior Authorizaon Request form.
Desjardins Insurance life health rerement logo
Last name and rst name of the member (PLEASE PRINT) Contract No. Cercate No.
Email address of the member
Signature of the member Date
Last name and rst name of the parent or legal guardian (if necessary)
Signature of the parent or legal guardian (if necessary) Date
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 
  
  
  
   
   
 
  

No

  

PROGRAM






g

 

 
No


g
 
No









12505E (2020-08)


     








 
 

 
 
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NEW REQUEST







 
      


 B
 Yes  
 Yes  
 Yes 


   
 
  

  
 Yes 

    2  




 Yes 
 Yes  







 Yes 
 Yes 


 Yes 
  

OUTCOME








  

  



  
  









  
  
  
  
  
  
  


      
















•  







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• 


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Completed 9 February 2021

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