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. Information Received from 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. Federal Law (including HIPAA) requires a signed authorization in order for Amgen to collect this information from my Health Care Providers. 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. 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 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. If I cancel my consent, I will no longer qualify for the services described. I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen at 88 or by writing to PO Box 7249, Bedminster, NJ 07921. 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 also understand I am authorizing my personal information, including my personal health information, to be used for 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 and business partners, who are performing the services set forth 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.Įxpiration, Right to Obtain a Copy and Right to Cancel
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 thisĪuthorization. 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. This may include select information from or about my medical 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”). 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 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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