By submitting this form, the patient gives their permission to share their individually identifiable health information with Celltrion USA, Inc., Celltrion affiliates and its vendors (collectively, “Celltrion”).
The patient understands that their individually identifiable health information may include their full name, address, demographic information, information related to medical condition, care management, and prescriptions (collectively, “Health Information”), whether in written or verbal form. The patient’s Health Information will be shared with Celltrion so that Celltrion may provide them with various support and information to help them access a Celltrion medicine, which may include the
following, depending on the program (collectively, “Patient Support Activities”):
- • Processing this form;
- • Verifying the information provided in this form
- • Providing them with access to Nurse Connectors who can assist in medication and adherence communications, medication dispensing support, and supplemental injection training; and
- • Providing them with disease management and other educational materials, as well as information about Celltrion’s products, services, and programs, and may include sending them surveys about their experience with Celltrion products, services, and programs; and Celltrion also may use their Health Information for auditing for compliance with Program requirements, quality assurance purposes, and to evaluate and improve our operations and services.
The patient understands that they do not have to complete this form, and choosing not to complete will not affect their ability to receive treatment from their Healthcare Providers or payment from their health insurer. However, if they do not complete this form, Celltrion may not be able to provide them with assistance.
The patient understands that once their Health Information is shared, it may no longer be protected by federal privacy law. However, Celltrion agrees to protect their Health Information and to use it for the purposes described in this form or as required or permitted by law. Select pharmacies may receive remuneration from Celltrion in exchange for their Health Information and/or for any Patient Support Activities provided to them. The patient understands that this form will remain in effect for [4] years from the date of their consent or shall otherwise expire at a shorter duration as required under applicable State law, unless they provide written notice that they would like to withdraw their approval to share their Health Information sooner. MARYLAND HEALTHCARE PROVIDERS, under Md. Code, Health - Gen. § 4-303(b)(4), this authorization expires ONE YEAR from the date of consent. If the patient would like to withdraw their approval, they may contact Celltrion at 1-877-81CONNC (1-877-812-6662). This withdrawal will not affect the use or sharing of their Health Information that took place before they withdraw their approval. The patient understands that they may receive a copy of this form.
