Patient Authorization for Specialty Pharmacy
In accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations and rules
“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my health and personal
information to CooperSurgical, Inc. and it’s specialty pharmacy agents (and their aliates, respective representatives, and
agents) in furtherance of the below-stated authorized purposes.
I understand that the selected specialty pharmacy will receive my health and personal information, which may include my
name, address, patient insurance identiﬁcation number, date of birth and other information necessary to obtain health insurance
beneﬁt veriﬁcation for the following purposes: (1) the administration of CooperSurgical’s Paragard Program; (2) to conduct beneﬁt
veriﬁcation determining insurance reimbursement and coverage of Paragard; (3) to contact me to discuss any relevant co-pay;
(4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare provider; (7) to contact me by
telephone in furtherance of conducting beneﬁts veriﬁcations investigations and/or specialty pharmacy dispense; and (8) if I
choose to self-pay for Paragard, to invoice me and to otherwise contact me to collect payment for the Paragard unit.
By signing the following form, I understand:
1. Once my healthcare provider gives the selected specialty pharmacy information about me based on this Authorization, my
medical and health information may be subject to redisclosure and is no longer protected by federal privacy regulations.
I further understand and agree that the selected specialty pharmacy may retain my medical and health information as
disclosed under this Authorization after this Authorization expires.
I also understand that in the event of an audit, and for purposes of such an audit, some information may also be disclosed to
CooperSurgical, Inc., the manufacturer of Paragard, or its aliates after this Authorization has expired, so long as the audit is
for a period of time when this Authorization was in eect.
2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not aect my ability to
obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance beneﬁts.
3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider, health plan and/or
pharmacy that refers to (or with a copy of) this Authorization form, or to the selected specialty pharmacy. I understand that if
I revoke this Authorization, it will not aect prior disclosures made to the selected specialty pharmacy and any use of such
information by the selected specialty pharmacy in reliance of this Authorization. I understand that I have the right to receive
a copy of this Authorization.
4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.
Signature of Patient or Legal Personal Representative: Date: / /
Name of Patient or Legal Personal Representative:
(If Applicable) Description of Personal Representative’s Authority to Sign for Patient:
Please see Important Safety Information and
Full Prescribing Information for Paragard at Paragard.com.
is a registered trademark, and Paragard Specialty Pharmacy
is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc. C-US-PAR-000041 October 2020