I authorize my/the patient’s healthcare providers and their staff (including those pharmacies that may receive my/the patient’s prescription for Dysport®) to disclose personal health information (“PHI”) about me/the patient, including health information relating to my/the patient’s medical condition, prescription, and insurance coverage, to Ipsen Biopharmaceuticals, Inc., its affiliates, and its agents that have been hired to administer the Ipsen Coverage, Access, Reimbursement & Education Support (IPSEN CARES) program on its behalf (collectively “Ipsen”) in order for Ipsen to: (1) enroll me/the patient in the IPSEN CARES Patient Assistance Program (the “PAP”) if I/the patient am/is eligible; (2) establish my/the patient’s benefit eligibility for assistance related to potential out-of-pocket costs for Dysport®; (3) send me information about the PAP and other programs that might help me/the patient pay for my/the patient’s medicines; (4) help get Dysport® shipped to my/the patient’s healthcare provider; and (5) facilitate my/the patient’s participation in Dysport® patient programs as I have requested or may request.
I agree that, using the contact information I provide, Ipsen may contact me for reasons related to the IPSEN CARES PAP to (1) determine if I/the patient am/is eligible for assistance and related support services; (2) leave messages for me that may disclose that I/ the patient am/ is or am not/is not eligible for assistance; (3) operate the PAP and other programs that might help me pay for my/the patient’s medicines; (4) send my/the patient’s information to other programs that might help me pay for my/the patient’s medicines; (5) ask me for financial insurance, and/or medical information; and/or (6) share my/the patient’s information as required or permitted by law. I authorize the PAP to use information on this application and any other information I give to the PAP for these same reasons. I also give Ipsen permission to share my/the patient’s PHI and other information with people and companies that work with the PAP; government agencies, including the Centers for Medicare and Medicaid Services; insurance companies, including Medicare Part D plans; my/the patient’s doctor(s) and other people, or institutions who are involved in my/the patient’s healthcare, such as pharmacies and hospitals; and/or other organizations that might help me pay for my/the patient’s medication. All information that I provide may be used by Ipsen, or any third party working on behalf of Ipsen, in connection with the PAP. I also consent to being contacted by an IPSEN CARES program representative to obtain further information or clarification regarding any adverse event I/the patient may experience.
I understand that once my/the patient’s PHI has been disclosed to Ipsen, privacy laws may no longer restrict its use or disclosure. However, Ipsen agrees to protect my/the patient’s information by using and disclosing it only for the purposes described above or as required. I understand that my/the patient’s healthcare providers may receive remuneration from Ipsen in exchange for my/the patient’s PHI and/or for any therapy support services provided to me/ the patient.
I can withdraw this authorization by calling IPSEN CARES at 1-866-435-5677 or mailing a letter requesting such revocation to IPSEN CARES, 11800 Weston Parkway, Cary, NC 27513, but it will not change any actions taken before I withdraw this authorization. Withdrawal of this authorization will end further uses and disclosures of PHI by the parties identified in this form except to the extent those uses and disclosures have been made in reliance upon my authorization. I understand that I may refuse to sign this form and, if I do so, I/the patient will not be able to participate in the PAP, but it will not affect my/the patient’s eligibility to obtain medical treatment, my/the patient’s ability to seek payment for this treatment, or affect my/ the patient’s insurance enrollment or eligibility for insurance coverage. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time.
I understand that I will receive a copy of the signed authorization. I promise that any information, including financial and insurance information, that I provide to the PAP is complete and true, and unless I have said something different in this application, I have no insurance coverage for this product, which includes Medicaid, Medicare, or any public or private assistance programs, or any other form of insurance. If my income or health coverage changes, I will notify IPSEN CARES at 1-866-435-5677. I understand that Ipsen has the right to contact me directly to confirm receipt of medications. Ipsen may revise, change, or terminate this program at any time.