EFTA00298075.pdf

RepathaReady" Universal Patient Authorization Form RepathaReady Repatha. 0 Fax this form back with the patient's demographic information (evolocumab) and signature to: 1-855-REPATHA (1-855-737-2842). Patient Information Piront'', me' Pretend Phone( ) Street Addres c• EmailAddress: City':_ St≥te': 7ip• Date of Birth*: Social Security M. Prescriber Information Office Contact kg i.f ri Ng IMW Off ce Street Address': Vat Ritre.1 -47X S/. Email Address: ity.: da 4rA State: Al /Zit. /0 °I ? Prescriber Name': RtAl 7 SHIMMY Telephone':( Wally 642COOLOr4 / Fat ( 24? 374 - 3190 ofta Name 417. \UAW/ year' icrettatdir Prescriber NFI il*: Repatha Ready' Program Privacy Notice and Authorization In accordance with my signature below, 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 in the Patient Privacy Authorization other than promotional communications by telephone or SMS/text (to which I can separately opt-in below). 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. My preferred methods) of contact 0 Email LI Phone 0 Mail 0 SMS/text (standard text message charges may apply from your wireless provider) 0 In addition to the above consent, I understand that by checking this box and signing below, I consent to Amgen calling and texting me at the phone number(s) I have provided with promotional communications relating to Amgen products and services and/or my condition or treatment. Amgen may use automatic dialing machines or artificial or prerecorded messages to contact me and may leave a voicemail or text message (standard text messaging rates may apply). I understand that I am not required to provide this consent as a condition of purchasing any goods or services. My signature below certifies that I am at least 18 years old and that I have read, understand, and agree to the Privacy Notice and Patient Authorization to release my personal health information as described in full detail on the next page. Patient Name: Name of Legal Guardian (if needed): Patient Signature (or Legal Guardian): X Date: 'Required ler processing. The Repathe Patient Start Program Is not available In Massachusetts, Puerto Rico. or where prohtbed by law. Please see Me nen page for the ReparieRor Prone Prheor Rote andkmrodzation. 0 2016 Amgen bo.All rights reserved RepathaReadf Phone: 1.844-REPATHA (737-2842), Hours: 9 m-9 RA ET, M-F; Fair 1.855-REPATH4 (737-2842) USA-145-120958 EFTA00298075 RepathaReadr Patient ID #: Physician NPI _I RegathaReadr Program Repatha• Privacy Notice and Authorization (evolocumob)Om&ml Amgen's Privacy Pledge to Patients Amgen respects patients and customers and takes the protection of their privacy very seriou§y. Amgen pledges the following: ✓Amgen does not and will pot sell or rent your information to marketing companies or mailing list brokers. ✓ Amgen is careful to only collect and/or use personal identifiable information for the purposes stated in this Authorization and as =MIX to provide the services and/or programs the patient or customer chooses to enroll into. ✓ Amgen practices are consistent with federal and state privacy laws including HIPAA. ✓ Amgen program enrollment is voluntary and always provides patients with an easx option to cancel participation. 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, only for the following purposes • To operate, administer, enroll me in, and/or continue my participation in Amgen's RepathaReady" 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 reeds to cotiect and use my personal information, including mypersonal 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 historyand 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 personalhealth 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 personalhealth information and/or for using my information to contact me with communications about Amgen products which have been prescribed to me (for ex. adherence 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 migli 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 persenal 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 tine by calling Amgen at 1-844-REPATHA or by writing to PO Box 220326 Charlotte, NC 28222. If I cancel my consent I will no longer qualify for the servees 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 en 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 ming and disclosing it as stated in the Authorization or as otherwise allowed or required by law. I understand that Amgen does not and will not sell or rent my information to marketing companies or mailing list brokers. AMGEN' O 2016 Amgen Inc NI riMreserved. RepathaRear Phone: 1-844-REPATHA (737-2842), Hours: 9 ar-9 FM El; M-F, Fax 1-855-REPATH4 (737-2842) USA-145.120956 EFTA00298076