VIATRIS and the Viatris Globe logo are trademarks of Mylan Inc., a Viatris Company.
© 2021 Viatris Inc. All rights reserved. viatris.com/pap
Viatris Patient Assistance Program Application
| Phone: 888-417-5780 | Fax: 877-427-7290 | M-F, 8
AM
to 5
PM
EST |
Patient Signature:
Date:
By signing this Authorization, I authorize each of my physicians, pharmacists, including any non-commercial pharmacy that receives my prescription (“my Prescribed
Product”), and other healthcare providers (together “Healthcare Providers”) and each of my health insurers, if any (together, “Insurers”) to disclose my Protected Health
Information, including but not limited to medical records, information related to my medical condition and treatment, my health insurance coverage, my name, address,
telephone number, Social Security number, insurance plan and or group numbers (together, “Protected Health Information”) to Viatris, its affiliated companies, vendors,
agents, collaboration partners, and representatives (together, “Viatris”) including providers of alternate sources of funding for prescription drug costs, and other service
providers supporting the Viatris Patient Assistance Program (PAP) (collectively, the “Program”) for the purposes described below.
Specifically, I authorize disclosure of my Protected Health Information in order to:
I. Enroll me in, and contact me about the Program, including online support, financial assistance services, and co-pay assistance services, as applicable,
II. Communicate with my Healthcare Providers and Insurers about benefits, coverage, and medical care, including compliance with Product treatments,
III. Facilitate dispensing of my prescription by a non-commercial pharmacy,
IV. Provide me with educational materials, information and services related to my treatment experience with my prescribed medication
and my condition,
V. Verify, investigate, and coordinate with my Insurers regarding my prescribed medication, and
VI. Contact me as otherwise required or permitted by law.
Once my Protected Health Information has been disclosed to Viatris, I understand that federal privacy laws no longer protect the information. However, Viatris agrees
to protect my Protected Health Information by using and disclosing it only for the purposes described in this Authorization or as permitted by law. I understand that I may
refuse to sign this Authorization. My choice about whether to sign will not change the way my Healthcare Providers or Insurers treat me, but I will not have access to the
Viatris Patient Assistance Program and the services provided by Viatris under the Program. If I refuse to sign the Authorization, or revoke my Authorization later, I
understand that this means I will not be able to participate in or receive assistance from the Program.
I understand that my signed Authorization is valid for 5 years from the date of my signature, and that I may revoke this Authorization at any time in the future, except to
the extent that actions have been taken in reliance on the Authorization. I understand that to revoke this Authorization I may mail a request to 5005 Greenbag Road
Morgantown, WV 26508, fax to 877-427-7290, or by calling 888-417-5780. I understand that revoking this Authorization will end further uses and disclosure of my
Protected Health Information by the parties identified above except to the extent those uses and disclosures have been made in reliance upon this Authorization as
permitted by applicable law. I am entitled to receive a copy of this Authorization.
I understand that if I qualify and I am enrolled in the Program sponsored by Viatris, I will receive my Prescribed Product from Viatris only pursuant to a legally valid
prescription from my health care provider. I understand that if I qualify and I am enrolled in the Program, Viatris will provide me my Prescribed Product free of charge for
the duration of the enrollment period so long as I have a legally valid prescription for my Prescribed Product. I understand that I am not required to continue treatment
with my Prescribed Product if I gain insurance coverage, or to receive treatment from any given provider. I understand and agree that I must notify Viatris PAP at
888-417-5780 immediately if my insurance status changes during the Program enrollment period. I understand and agree that neither I nor my Insurers, if applicable,
will be charged for the supply of my Prescribed Product that I received from the Program, and that under NO circumstances may I claim reimbursement from my
Insurers or any other third party for the Prescribed Product provided to me free of charge from the Program. I understand that Viatris reserves the right at any time
without notice to modify or discontinue the Program and its criteria.
I understand that I am providing ‘written instructions’ to Viatris under the Fair Credit Reporting Act authorizing Experian on behalf of Viatris to obtain information from my
credit profile or other information from Experian. I authorize Viatris and its service providers to obtain such information solely for the purpose of determining financial
qualifications for the Program. I understand that I must affirmatively agree to the terms in this notice by signing below in order to proceed in the Program financial
screening process.
My signature certifies that I have read and understand the above statements and agree to the outlined terms.
P
tient Name
(Print)
:
Patient Signature: Date:
I permit Viatris PAP Support Services representatives to speak with the following person about this application form. This includes discussing the status o
my application, insurance and financial questions, any missing documentation and other issues related to my enrollment, or any other treatment- related
issues. I may cancel this Patient Authorized Representative Authorization at any time by calling: 888-417-5780
Name of Authorized Representative:
Relationship to Patient:
Telephone Number:
Email:
By signing below, I, the patient, allow this representative to speak on my behalf on any matter regarding my enrollment with the Program.
Patient Authorization and Agreement Signature
Patient Authorized Representative
Downloaded from NeedyMeds.org
