Trademarks are owned by or licensed to the ViiV Healthcare group of companies.
©2020 ViiV Healthcare or licensor. ADR 2020.01 VC Enrollment Form English (Digital) 1001
January 2020 Produced in USA.
PATIENT AUTHORIZATION AND RELEASE
PATIENT AUTHORIZATION AND RELEASE (SIGNATURE REQUIRED)
ViiVCONNECT.COM • PHONE: 1-844-588-3288 • FAX: 1-844-208-7676
Complete, sign, and electronically submit all pages of this form and applicable corresponding documents (including the prescription)
through the portal, or fax to 1-844-208-7676 (toll-free).
For assistance, please call 1-844-588-3288 (toll-free), Monday through Friday, 8
am to 11 pm ET.
Patient Representative
†
Name (please print):
Signature (stamped signature not accepted):
Date:
Relationship to Patient:
PATIENT REPRESENTATIVE CERTIFICATION
By my signature, I certify to the best of my knowledge that the information on this Enrollment Form is correct and complete. I have no knowledge of any intent to sell,
barter, or give any free medicine received under the Patient Assistance Program to any person other than the Patient for whom it has been prescribed. To the best of
my knowledge, the information about the Patient on this Enrollment Form is complete. I acknowledge that the programs through ViiVConnect do not constitute health
insurance. My signature above also serves as attestation that the Patient has authorized me to act on their behalf. As the Patient’s Representative, I authorize ViiV
Healthcare and any other companies that ViiV Healthcare uses to collect, use, and disclose the Patient’s information. I also understand that I have the right to revoke
this authorization on behalf of the Patient at any time by calling 1-844-588-3288 or mailing a signed, written statement of my revocation to ViiVConnect, PO Box 220100,
Charlotte, NC 28222-0100, but that such a revocation would end my eligibility to participate in the programs as described. Upon receipt and processing of written
revocation of this authorization, further disclosures of Protected Health Information will be prohibited. However, certain information may still be collected, used, and
disclosed for administrative purposes by ViiV Healthcare or any other companies that ViiV Healthcare uses to collect, use, or disclose such information.
Patient (REQUIRED)
Name (please print):
Signature:
Date:
Page 2 of 2
†
Only complete this section if the Patient Representative enrolls the Patient and wants to be the contact person and receive program
correspondence on behalf of the Patient.
If applicable, I authorize a Patient Representative to act on my behalf pursuant to the Patient Representative Yes No*
Certification below.
I authorize ViiVConnect to provide me with information on my benefits and other Phone Text Email Any
communications that contain reference to ViiVConnect through the following:
If I am unavailable when contacted, I authorize ViiVConnect to leave a voicemail with the Access Coordinator’s name, Yes No*
a reference to ViiVConnect, and a call back phone number.
*If I do not authorize ViiVConnect to leave a voicemail with the Access Coordinator’s name, a reference to ViiVConnect, and a call back phone number, I will be
responsible for contacting ViiVConnect.
I certify that the information provided within this Enrollment Form and Patient
Authorization and Release is true and correct. I understand that the collection,
use, and disclosure of certain information is protected under law. I understand
that Information contained in this Enrollment Form, such as my name, address,
insurance, prescription, and medical information, is “Protected Health Information.”
By signing below, I agree to the collection, use, and disclosure of my Protected
Health Information as described below. I understand that my healthcare providers
will not base any medical treatment decisions on my agreement to sign this Patient
Authorization and Release. I also understand that my agreement to sign this
Patient Authorization and Release and enroll in ViiVConnect is not required for my
valid prescription to be filled. I understand that once Protected Health Information
is collected, used, and/or disclosed based on this executed authorization, federal
privacy laws may not prevent the entities described below from further disclosing my
information. However, I understand that such entities have agreed to collect, use,
or disclose Protected Health Information received only for the purposes described
in this authorization or as required by law. I understand that ViiV Healthcare does
not charge a fee for participation in ViiVConnect programs. If my authorized
Patient Representative charges a fee for enrollment or refills of my free medicine
received under the Patient Assistance Program, this money is not paid by or paid
to ViiV Healthcare. I certify that any product that I receive from ViiV Healthcare is
for my own use and will not be sold, bartered, or given to any other person. I certify
that the information provided in this Enrollment Form is complete and accurate to
the best of my knowledge and agree to notify ViiVConnect of any change in my
insurance eligibility or financial status. I understand that this authorization will remain
in eect for two (2) years, unless a shorter time period is mandated by state law. I also
understand that I have the right to revoke this authorization at any time by calling
1-844-588-3288 or mailing a signed, written statement of my revocation to
ViiVConnect, PO Box 220100, Charlotte, NC 28222-0100, but that such a revocation
would end my eligibility to participate in the programs as described. Upon receipt
and processing of written revocation of this authorization, further disclosures of
Protected Health Information will be prohibited. However, certain information
may still be collected, used, and disclosed for administrative purposes by ViiV
Healthcare and any other companies that ViiV Healthcare uses to collect, use,
and disclose such information.
Enrollment in ViiVConnect: The Patient and, if applicable, the Patient Representative
MUST sign this Patient Authorization and Release. Patient Representative must define
their relationship to the Patient in the designated box below.
By signing this Patient Authorization and Release, I authorize ViiV Healthcare and any
other companies that ViiV Healthcare uses to collect, use, or disclose my Protected
Health Information to do the following:
1. Request and receive from my doctor, healthcare provider, health insurer, or
pharmacist information necessary to investigate and resolve my insurance
coverage, coding, or reimbursement inquiry, or review my eligibility for Patient
assistance programs and co-pay assistance.
2. Collect, use, and disclose to each other any information that I provide to
ViiVConnect for investigating and resolving my insurance coverage, coding, or
reimbursement inquiry.
3. Disclose to my treating physician, healthcare provider, or pharmacist information
I provide to ViiVConnect when necessary to resolve my insurance coverage,
coding, or reimbursement inquiry. I also authorize my insurer, doctor, healthcare
provider, and pharmacist to release information about my prescribed medications
and medical condition requested by ViiVConnect.
4. Contact my insurer, other potential funding sources, social workers, Patient
advocacy organizations, and/or Patient assistance programs on my behalf to
determine if I am eligible for health insurance coverage or other funds and disclose
to them information about my prescribed medications and medical condition that
has been provided to ViiVConnect by me or my physician, healthcare provider, or
pharmacist.
5. Disclose any information obtained from the sources listed above to third parties if
required by law.
6. Request additional documents and information at any time, even if I am already
enrolled so that ViiV Healthcare can determine if the information on this form is
complete and true.
Downloaded from NeedyMeds.org
