PATIENT AUTHORIZATION
Phone: 1-877-714-AXIS (2947)
Fax: 866-823-9554
Patient Name: ____________________________________
Date of Birth: ____________________________________
Home Phone #: ____________________________________
AUTHORIZATION TO USE AND DISCLOSE HEALTH
AND OTHER PERSONAL INFORMATION
I authorize my physician and their staff to disclose my health
and other personal information, including, but not limited to, the
information on my completed Statement of Medical Necessity
form and, if eligible, the application for EMD Serono’s Patient
Assistance Program and any confidential HIV-related information,
if applicable, including HIV test results, to EMD Serono, Inc. and
its agents and representatives (collectively “EMD Serono”) so
that EMD Serono may use and further disclose my information
to healthcare providers, pharmacies, insurance companies,
prescription drug plans, and other third-party payers (collectively,
“Third Parties”) in order to:
(1) facilitate the filling of my prescription for and the delivery and
administration of Serostim
®
;
(2) assist me in obtaining insurance coverage for Serostim
®
;
(3) contact me by mail, e-mail, and/or telephone to enroll me in,
and administer, programs that provide Serostim
®
support
services;
(4) including to determine my eligibility to participate in the Patient
Assistance Program, and, if eligible, to verify the accuracy
of the information I provide in my application for the Patient
Assistance Program;
(5) provide me with free educational information and materials;
(6) conduct surveys to measure my satisfaction with patient
support services; and
(7) for such other purposes as may be required or permitted by
applicable law.
I further authorize the Third Parties to disclose health and other
personal information about me in their possession to EMD Serono
in order to assist EMD Serono in accomplishing the purposes
described above.
I understand that, once my information is disclosed pursuant
to this authorization, it may no longer be protected by federal
privacy laws (the Health Insurance Portability and Accountability
Act). However, I understand that EMD Serono will not release my
information to any party, except as provided in this authorization or
as permitted by applicable law, without first obtaining my (or my
authorized representative’s) separate written consent.
I understand that I may refuse to sign this authorization and
that such refusal will not affect my ability to receive Serostim
®
,
but, if eligible, it will limit my ability to participate in the Patient
Assistance Program.
I understand that this authorization will remain in effect for ten
years from the date of my signature, unless I revoke it earlier
by contacting EMD Serono in writing at One Technology Place,
Rockland, MA 02370.
If I revoke this authorization, EMD Serono will stop using and
disclosing my information as soon as possible, but the revocation
will not affect prior use or disclosure of my information in reliance
on this authorization.
I understand that the services provided by EMD Serono that are
described in this authorization can be changed at any time, without
prior notification.
I understand that certain Third Parties may receive compensation
in exchange for their disclosure of my information to EMD Serono.
I also understand that I have the right to receive a copy of this
authorization.
Patient Name (please print)
Signature of Patient (or personal representative)
Date / /
Authority/Relationship of Personal Representative to Sign on
behalf of Patient (if applicable)
Street Address:
________________________________________
City: _____________________ State: _________
Zip: ________________________________________
