Uses and Disclosure of Personal Information
I authorize Amgen and its contractors and business partners (“Amgen”) to use and/or
disclose my
personal information, including my personal health information, for the following
purposes only:
- To operate, administer, enroll me in, and/or continue my participation in the
Amgen® SupportPlus
Co-Pay Program or any other Amgen-affiliated patient support services and
activities 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
management support);
- To contact, with my permission, my doctor and the rest of my health care team
and share with them my
health information that may be useful for my care;
-
To provide me with informational and promotional materials relating to
Amgen products and
services, and/or my condition or treatment; and/or
- To improve, develop, and evaluate products, services, materials, and programs
related to my
condition or treatment.
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. I
understand 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,
pharmaceutical
company, laboratory and/or their contractor (“health care provider”). This may
include select
information from or about my medical history and general health, my health care plan
benefits, payment
limits or restrictions covered by my health care plan policy, and/or my adherence to
my treatment.
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. I understand
that certain of my health care providers (such as pharmacies and specialty
pharmacies) may receive
remuneration from Amgen in exchange for disclosing my 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) and other patient support services.
Expiration, Right to Obtain a Copy, and Right to Cancel
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 and business
partners, who are performing the services set forth in this Authorization. I also
understand I am
authorizing my personal information, including my personal health information, to be
used for the
purposes described above. 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) years or
until my participation in the program ends through my cancellation, unless a shorter
time period is
required by state law.
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. If I
cancel my consent, I will no longer qualify for the services described. 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.
No Effect on Treatment
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 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. Federal Law (including HIPAA)
requires a signed
authorization in order for Amgen to collect this information from my 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.
Information Received from Health Care Providers
I understand that once my personal health information has been disclosed to Amgen,
federal privacy laws
may no longer apply and protect it from further disclosure. Amgen agrees, however,
to protect my
personal health information by only using and disclosing it as stated in the
Authorization or as
otherwise allowed or required by law.
Authorization to Contact
I understand and consent to Amgen contacting me using the contact information
provided in this form to
enroll me in, operate, and administer Amgen patient support services and/or programs
as described above
other than promotional communications by telephone or SMS/text (for which I can
separately opt-in). I
understand that the operation and administration of certain of these services and/or
programs may
require that Amgen contact me by telephone or SMS/text.
By checking the “I Agree” box, I am electronically indicating that I have read and
understood Amgen’s
Patient Authorization (above in its full text), that I am legally authorized to
consent, and that I am
providing my consent as the patient or the patient’s legal guardian for Amgen and
its contractors and
business partners to use and share the personal information I provide for the
purposes described within
the Patient Authorization. By exiting the page my enrollment will be discontinued.
