I agree to be contacted by Amgen by mail, email, telephone calls and text messages at the numbers and address(es) provided on this Form for all purposes described in this Patient Authorization. I also understand that the AimAlly ™ support program may change or end at any time without prior notification. I understand that this authorization will remain valid for 5 years after the date of my signature, unless I revoke it earlier. If I revoke this authorization, Amgen will stop using or sharing my information (except as necessary to end my participation in the program), but my revocation will not affect uses and disclosures of personal information previously disclosed in reliance upon this authorization. ![]() My refusal or future revocation will not affect my medical treatment or insurance benefits however, if I revoke this authorization, I may no longer be able to participate in the AimAlly ™ support program and related programs. I also understand that if a Healthcare Provider or Insurer is disclosing my personal information to Amgen on an authorized, ongoing basis, my cancellation with Amgen will be effective with respect to any such Healthcare Provider or Insurer as soon as they receive notice of my cancellation. I also may revoke (cancel) or get a copy of this authorization at any time by calling 83 or writing to PO Box 2205, Morristown, NJ 07962. I understand that I may refuse to sign this authorization. I understand that once my personal information is disclosed, it may no longer be protected by federal privacy law. I understand that my Healthcare Providers and Insurers may receive remuneration (payment) from Amgen in exchange for disclosing my personal information to Amgen and/or for providing me with therapy support services. ![]() I give permission to Amgen to disclose my personal information to my Healthcare Providers for the purposes described above. (viii) conduct quality assurance, surveys, and other internal business activities in connection with the AimAlly ™ support program and other related programs. (vii) provide me with medication reminders and support and (vi) If I am eligible, coordinate the Aimovig ® Copay Card program, including managing and communicating with me about the copay support options available to me (v) manage the AimAlly ™ support program ![]() (iv) provide me with information about Amgen products, disease education and awareness and management programs, and promotional materials related to my condition or treatment (ii) coordinate my receipt of and payment for Aimovig ® (i) help to verify or coordinate insurance coverage or otherwise obtain payment for my treatment with Aimovig ® (erenumab-aooe) Give permission for my healthcare providers, pharmacies, service providers and their contractors ("Healthcare Providers"), and health insurers and their contractors ("Insurers"), to disclose my personal information, including information about my health insurance benefits, prescriptions, my medical condition and history, adherence to my treatment, and my general health ("personal information") to Amgen Inc., its affiliates, business partners, and agents ("Amgen") for the following purposes: I give permission for my healthcare providers, pharmacies, service providers and their contractors (“Healthcare Providers”), and health insurers and their contractors (“Insurers”), to disclose my personal information, including information about my health insurance benefits, prescriptions, my medical condition and history, adherence to my treatment, and my general health (“personal information”) to Amgen Inc., its affiliates, business partners, and agents (“Amgen”) for the following purposes:
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |