Information provided in this form to enroll me in, operate,Īnd administer Amgen patient support services and/or programs asĭescribed above other than promotional communications by telephone I understand and consent to Amgen contacting me using the contact
Protect my personal health information by only using andĭisclosing it as stated in the Authorization or as otherwise I understand that once my personal health information has beenĭisclosed to Amgen, federal privacy laws may no longer apply and Information Received from Health Care Providers I understand I cannot participate in the listed services and/or programs without signing this Authorization or an equivalent authorization with my Health Care Providers. Federal Law (including HIPAA) requires a signed authorization in order for Amgen to collect this information from my Health Care Providers. I understand that Amgen, as well as Health Care Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment or other care, to sign this Authorization. I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely voluntary. I also understand that if a Health Care Provider is disclosing my personal health information to Amgen on an authorized on-going basis, my cancellation with Amgen will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation. If I cancel my consent, I will no longer qualify for the services described. I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen SupportPlus at 1-833-44AMGEN (1-83) or by writing to PO BOX 2135, Morristown, NJ 07962-9927. Signing below, I am authorizing those who rely on thisĪuthorization to release my personal health information for theĮarlier of five (5) years or until my participation in the programĮnds through my cancellation, unless a shorter time period is Information, including my personal health information, to be usedįor the purposes described above. I also understand I am authorizing my personal Release it to Amgen employees, as well as to its contractors andīusiness partners, who are performing the services set forth in Providers or others who might hold my health information to only I understand that by signing this form, I authorize my Health Care Personal health information and/or for using my information toĬontact me with communications about Amgen products which haveīeen prescribed to me (for example medication reminder programs)Įxpiration, Right to Obtain a Copy and Right to Cancel Receive remuneration from Amgen in exchange for disclosing my Providers (such as pharmacies and specialty pharmacies) may I understand that certain of my Health Care Health information to Amgen, and between themselves,Īs necessary, but only for the purposes stated above in thisĪuthorization. I authorize my Health Care Providers to disclose my personal My health care plan benefits, payment limits or restrictionsĬovered by my health care plan policy, and/or my adherence to my Information from or about my medical history and general health, Pharmacy, pharmaceutical company, laboratory and/or theirĬontractor (“Health Care Provider”). Of or derived from a health care provider, health care plan, Information, in electronic or physical form, in the possession I understand that my personal health information may include any Information, including my personal health information. In order for Amgen to provide me with the services and/or programsĭescribed above, Amgen needs to collect and use my personal Materials and programs related to my condition or treatment. To improve, develop, and evaluate products, services,.Relating to Amgen products and services, and/or my condition To provide me with informational and promotional materials.Health care team and share with them my health information that To contact, with my permission, my doctor and the rest of my.Verification, nurse educator services, adherence program and Programs, reimbursement assistance programs, drug coverage Related to my condition or treatment (for example, co-pay Participation in Amgen ® SupportPlus program or any otherĪmgen-affiliated patient support services and activities To operate, administer, enroll me in, and/or continue my Including my personal health information, only for the following
(“Amgen”) to use and/or disclose my personal information, I authorize Amgen and its contractors and business partners Uses and Disclosure of Personal Information
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