FORM-HIPAA Consent HIPAA Authorization Consent Form This form authorizes the release of your medical information for patient support services. HIPAA Consent(Required)PATIENT AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION By signing and printing my name below, I authorize 1. my prescribing healthcare provider, 2. the healthcare provider who will administer VIVITROL to me, 3. the pharmacy(ies) to which my VIVITROL prescription is sent for fulfillment (the “Pharmacy”), and 4. my health plans and insurers (collectively, my “Healthcare Entities”) to use and disclose to: 1. Alkermes, Inc. and the companies working with Alkermes, Inc. to provide the VIVITROL patient support services I request, which are United BioSource Corporation, IQVIA, Inc., (collectively, “Alkermes”) and 2. my Contact(s) listed above (together with Alkermes, the “Recipients”) health information related to my medical condition, including information about my drug or alcohol addiction, my mental health condition(s), my treatment with VIVITROL, my insurance coverage, as well as the information requested in this form (taken together, “Information”) for the specific purposes of allowing Alkermes to facilitate: 1. ordering, delivering and administering VIVITROL, 2. conducting reimbursement verification and obtaining payment from my health plan(s) and insurer(s), 3. providing me with educational and therapy support services by mail, text-messaging, e-mail, and/or telephone, which may include sending me product information materials, treatment reminders, and motivational messages, 4. referring me to, or determining my eligibility for, other programs, foundations or alternative sources of funding or coverage to help me with the costs of VIVITROL and 5. reviewing and analyzing fulfillment of VIVITROL prescriptions. Information May Be Further Disclosed: I understand that Information disclosed pursuant to this authorization could be re-disclosed by a Recipient and may no longer be protected by federal privacy law (HIPAA). I understand that signing this authorization is voluntary and if I do not sign this authorization it will not affect my ability to obtain treatment, insurance, or insurance benefits from my Healthcare Entities. I understand, however, that if I do not sign this authorization, I will not be eligible to receive the educational, patient support, or other services described above, which are being provided by, or on behalf of, Alkermes. I will consult with my healthcare provider before making any treatment decisions. I understand I have the right to receive a copy of this authorization after I sign. I understand that the Pharmacy may receive payment from Alkermes, Inc. in exchange for Information. I may withdraw this authorization at any time by mailing or faxing a written request to Vivitrol2gether, 852 Winter Street, Waltham, MA 02451, 1-877-329-8484. I agree.(Required)Contacts Consent(Required)By signing below, I authorize my Contact(s), listed below, to receive logistical and administrative information related to my treatment, such as appointment reminders, and to make decisions on my behalf—for which I will remain liable—regarding the delivery of VIVITROL® (naltrexone for extended-release injectable suspension). Alkermes is not liable for any decision(s) made by the Contact(s) or actions taken in reliance on such Contact(s) decisions. I agree.(Required)Patient Name(Required) First Last Date of Birth:(Required) Email(Required) Date:(Required) Please list any contacts as set forth above.Designee 1 Name: First Last Designee 1 Phone:Relationship to Patient Designee 2 Name: First Last Designee 2 Phone:Relationship to Patient: Co-pay Savings Program Information for Eligible PatientsBy signing below, I certify that: I am at least 18 years old, and I am being treated for opioid dependence or alcohol dependence. I am not enrolled in, or covered by, any local, state, federal, or other government programs that pays for any portion of medication costs, including but not limited to: •Medicare, including Medicare Part D and Medicare Advantage plans •Medicaid, including Medicaid Managed Care and Alternative Benefit Plans (“ABPs”) under the Affordable Care Act •Medigap If my insurance changes, I will promptly notify Vivitrol2gether at 800-848-4876 eligibility. I understand the eligibility requirements described above. I agree.Patient Name(Required) First Last Date:(Required) CommentsThis field is for validation purposes and should be left unchanged. Δ
