Healthcare PSP Document

Healthcare PSP Document

Program Enrollment — Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other

Emergency Contact

Insurance Information

Medical History

Patient Support Program Services Requested

I request enrollment in the Patient Support Program for assistance related to prescribed therapy, and authorize program staff to perform the selected services:

Medication supply coordination
Prior authorization assistance
Benefits and coverage investigation
Copay, co-insurance, or patient assistance program support
Refill and adherence reminders

Authorization to Use and Disclose Protected Health Information (PHI)

By signing below, I authorize my healthcare providers, pharmacies, insurer(s), and the Patient Support Program (PSP) to use and disclose my protected health information, including medical records, prescription information, insurance coverage, and payment information, to the extent necessary to facilitate enrollment in the PSP and to provide the services selected above. This authorization includes the exchange of information with pharmaceutical manufacturers and their service agents when needed to determine financial assistance eligibility, coordinate benefits, or secure product access.

Purpose of Disclosure: Coordination of clinical and financial support services, prior authorization processing, benefits verification, copay assistance administration, refill reminders, and other enrollment activities directly related to the PSP.

Expiration: This authorization will expire on , unless earlier revoked in writing. I understand that I may revoke this authorization at any time by providing written notice to the PSP, except to the extent that action has already been taken in reliance on this authorization.

Redisclosure: I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws. I release the PSP and its agents from any liability that may arise from such redisclosure where permitted by law.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the PSP privacy practices and the HIPAA Notice of Privacy Practices. I understand my rights to request restrictions, request confidential communications, and to inspect or obtain a copy of my protected health information, subject to applicable law and reasonable fees.

I acknowledge and agree

Communications & Contact Preferences

I authorize the PSP to contact me regarding program services, benefits, enrollment status, and medication support via the following methods (select all that apply):

Phone calls to primary phone
SMS / text messages to primary phone
Email to address provided above

Financial Authorization and Responsibility

I understand that enrollment in the PSP does not guarantee coverage, payment, or provision of any medication. If financial assistance is obtained on my behalf, I authorize the PSP to apply any manufacturer-provided benefits toward the cost of medication and related services as permitted by program terms. I agree to provide truthful and complete information for eligibility determinations and to notify the PSP of any changes to insurance or address that may affect program services.

I authorize my insurer to pay benefits directly to the pharmacy or other provider involved in dispensing medication, only as necessary for program administration. I accept responsibility for any amounts not covered by insurance or assistance programs, as required by the pharmacy or provider.

Revocation and Questions

I may revoke this authorization at any time by delivering a written revocation to the PSP. Such revocation will not affect disclosures made prior to receipt of the revocation. Questions regarding enrollment, revocation, or privacy should be directed to the PSP program contact provided at enrollment.

Certification

I certify that the information provided on this form is true and correct to the best of my knowledge. I understand and authorize the disclosures described above and acknowledge that my participation is voluntary and may be discontinued at any time by written notice.

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