For full Prescribing Information please visit www.rxabbvie.com
©2020 AbbVie Page 4 of 4 S-APP1-20A-1 January 2020
PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE
PATIENT: PLEASE READ AND SIGN IN SECTION 9
APPLICATION FOR SKYRIZI
D-617927, AP5 NE; 1 N. WAUKEGAN RD
NORTH CHICAGO, IL 60064
PHONE: 1-800-222-6885 FAX: 1-866-250-2803
HIPAA AUTHORIZATION, PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE
HIPAA AUTHORIZATION Please provide signature in Section 9 of Enrollment Form
I authorize my healthcare providers, pharmacies, insurers, and laboratory testing facilities (my “Healthcare
Companies”) to disclose information about me, my medical condition, treatment, insurance coverage, and
payment information in relation to my use of AbbVie products, to AbbVie to enroll me in and provide me with
patient assistance and support for AbbVie products. I understand that information released under this
Authorization will no longer be protected by HIPAA. I also understand that if my Healthcare Companies use
or disclose my Personal Information for marketing purposes, they may receive financial remuneration.
I understand that I am not required to sign this Authorization and that my Healthcare Companies will not
condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization.
However, I understand that if I do not sign this Authorization, I cannot take part in myAbbVie Assist (should I
qualify). This Authorization will expire in 10 years or a shorter period if required by state law, unless I cancel
it sooner by calling 1-800-222-6885 or by writing to myAbbVie Assist, D-617927, AP5 NE; 1 N. Waukegan
Rd, North Chicago, IL 60064. I understand that cancelling my Authorization will not affect any use of my
information that occurred before my request was processed.
PATIENT TERMS OF PARTICIPATION
myAbbVie Assist provides free medicine to qualifying patients. Participation in our program is free; we do not collect any fees from
people seeking our assistance. Medication assistance is dependent on your ability to meet the eligibility criteria for program as
determined by myAbbVie Assist. myAbbVie Assist does not have any obligation to provide the program services to you and is not
liable in the provision of these services. The program may be changed or discontinued without notice. You will not seek
reimbursement for any products dispensed under the program. You will notify the program if your insurance or financial situation
changes. If this application has been completed by a personal representative, the personal representative will provide a copy of this
completed application to you.
If you are a member of a Medicare plan including a Medicare Prescription Drug Plan and are qualified for program assistance, you
will: (i) be eligible to obtain the medication from the program for a calendar year term (ii) not purchase this medication under your
Medicare plan while enrolled in the program; (iii) not submit claims nor seek true out-of-pocket (TrOOP) credit for the medication
provided during your enrollment; (iv) provide written notification to your Medicare Prescription Drug Plan, if applicable, that you are
receiving your medication at no cost outside of the Medicare Part D benefit.
If you have questions, want to update your information, or terminate your enrollment, please call 1-800-222-6885 or write to us at
D-617927, AP5 NE; 1 N. Waukegan Rd, North Chicago, IL 60064.
PATIENT PRIVACY NOTICE
myAbbVie Assist will use and disclose with authorized third parties your personal information including your financial and health
information collected on this enrollment form and through participation in the program for the following purposes:
(1) To determine your eligibility for the program and to provide you with related services, including transfer to a separate private or
public payer program, reimbursement services, services to ship your medication, and other support services.
(2) To obtain information from your credit profile about your income for the sole purpose of determining eligibility for the program.
This notice serves as written instruction under the Fair Credit Reporting Act authorizing myAbbVie Assist to obtain this
(3) To perform research and data analytics to develop and evaluate products, services, materials, and treatments.
(4) To administer and maintain the quality of the program, including but not limited to case review, compliance checks, audit review
and accounting purposes.
For additional information on how AbbVie processes your personal information, please visit www.abbvie.com/privacy.html.
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