I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen at 1-844-REPATHA (737-2842) or by writing to PO Box 1366 Morristown NJ, 07962. Years or until my participation in the program ends through my cancellation, unless a shorter time period is required by state law. I understand and agree that by signing below, I am authorizing those who rely on this Authorization to release my personal health information for the earlier of five (5)
I also understand I am authorizing my personal information, including my personal health information, to be usedįor the purposes described above. I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to only release it to Amgen employees, as well as to its contractors andīusiness partners, who are performing the services set forth in this Authorization. Personal health information and/or for using my information to contact me with communications about Amgen products which have been prescribed to me (for example medication reminder programs) andĮxpiration, Right to Obtain a Copy and Right to Cancel Understand that certain of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Amgen in exchange for disclosing my I authorize my Health Care Providers to disclose my personal health information to Amgen, and between themselves, as necessary, but only for the purposes stated above in this Authorization. Payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment. This may include select information from or about my medical history and general health, my health care plan benefits, Pharmaceutical company, laboratory and/or their contractor (“Health Care Provider”). That my personal health information may include any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, In order for Amgen to provide me with the services and/or programs described above, Amgen needs to collect and use my personal information, including my personal health information.
Related to my condition or treatment (for example, co-pay card programs, reimbursement assistance programs, drug coverage verification, nurse educator services, adherence program and disease To operate, administer, enroll me in, and/or continue my participation in Amgen’s Repatha Ready ® program or any other Amgen-affiliated patient support services and activities I authorize Amgen and its contractors and business partners (“Amgen”) to use and/or disclose my personal information, including my personal health information, only for the following purposes: Uses and Disclosure of Personal Information
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