Patient resources consent:
By checking this box, I authorize my health plans, physicians and staff, other healthcare providers, and pharmacy providers (collectively, my “Providers”) to disclose information, including but not limited to, personal health information about me, including information related to my medical condition, treatment, care management, and health insurance coverage and claims, any prescription (including fill/refill information), and any other information disclosed in connection with the Resources (as defined below) (“Personal Health Information”), to CSL Behring and its representatives, agents, and contractors, including CSL Behring’s support program(s) (collectively “CSL Behring Entities”) for the purposes of the CSL Behring Entities:
(1) establishing my eligibility for insurance benefits including but not limited to coverage for prescription drugs;
(2) evaluating my eligibility for and enrolling me in one or more financial assistance program(s) offered by CSL Behring Entities,
such as a co-pay mitigation program and/or patient assistance programs (if one or more of such programs apply to my
treatment with a CSL Behring therapy);
(3) enrolling me in available patient services programs offered by CSL Behring Entities;
(4) communicating about my treatment with me or my Providers, including by contacting me directly to facilitate the
dispensing of medication and scheduling shipments and refill reminders;
(5) providing product support and adherence services to me through CSL Behring Entities;
(6) evaluating the effectiveness of CSL Behring’s support program(s);
(7) providing any other related support, education, and assistance services related to my treatment with CSL Behring therapy
and/or living with my disease; and
(8) contacting me for marketing or market research purposes (collectively, the “Services”).
Further, I authorize any of the CSL Behring Entities to contact me by mail, telephone and by text message in connection with any of the Resources.
I understand that once my Personal Health Information or other personal information is disclosed to the CSL Behring Entities under this authorization, it may no longer be protected by state and/or federal privacy laws and may be further disclosed by the CSL Behring Entities. However, I understand that the CSL Behring Entities will disclose my Personal Health Information only for the limited purposes described above, or as I may further authorize in writing, or as permitted or required by law. I understand that data related to my enrollment in any CSL Behring program may be collected, analyzed and shared among CSL Behring Entities.
I understand that my pharmacy Providers, including those Providers who dispense free trials as part of the Purposes or commercially-reimbursed doses of CSL Behring products, may disclose to the CSL Behring Entities certain Personal Health Information regarding the dispensing of my prescription and that such disclosure may result in remuneration to my pharmacy Provider(s).
I understand that I may refuse to sign this authorization. I understand, however, that if I do not sign this authorization, I may not be able to receive Resources through CSL Behring Entities. I understand that my treatment with a CSL Behring therapy (other than participation in a free trial program), payment for treatment, insurance enrollment, or eligibility for insurance benefits are not conditioned upon my agreement to this authorization.
I understand that I am entitled to a copy of this authorization.
I understand that I may change my mind and cancel this authorization at any time by writing a letter requesting such cancellation to CSL Behring c/o Patient Services P.O. Box 1587 Jeffersonville, IN 47130 or by calling 1-888-508-6978 and that this cancellation will end my participation in CSL Behring Resources. I also understand that my cancellation of the authorization will not invalidate any uses or disclosures of my Personal Health Information made before my notice of cancellation is received by CSL Behring Entities. This authorization expires five (5) years from the opt-in date, or earlier, if required by state law.
CSL Behring will not retain this data beyond the maximum period allowed by law.
