Authorization for Release of Medical Information
By submitting my application online I authorize Reach Patient Assistance, LLC (the “Company”) and any other companies that Reach Patient Assistance, LLC uses to administer Prescription Assistance Programs (the “Program”), to do the following:
1. Use any information that I provide in my application for the Program for the purpose of helping me receive medications under the Program or to administer the program;
2. Receive and keep records of all prescriptions for the medications I receive under the Program, which will be used to administer the program;
3. Contact my doctor, healthcare provider, or pharmacist about my application for the Program, and disclose to them information contained in my application, in order to help me receive medications under the Program and ensure that Program guidelines are being met;
4. Request information from my doctor, healthcare provider, or pharmacist about the prescribed medications received or will receive under the Program and about my medical condition. This information will be used only to determine my eligibility for the Program and to administer the Program. By signing below, I also authorize my doctor, healthcare provider, or pharmacist to release information about my prescribed medications and medical condition that is requested by Reach Patient Assistance, LLC or any company that Reach Patient Assistance, LLC uses to administer the Program;
5. Disclose any information obtained from the sources listed above to third parties if required by law;
6. Act in my behalf, as my attorney-in-fact, and to sign all forms and applications on my behalf and to access and release any required personal, demographic, diagnostic, therapeutic and/or financial information relating to applications for the Program.
1. Use any information that I provide in my application for the Program for the purpose of helping me receive medications under the Program or to administer the program;
2. Receive and keep records of all prescriptions for the medications I receive under the Program, which will be used to administer the program;
3. Contact my doctor, healthcare provider, or pharmacist about my application for the Program, and disclose to them information contained in my application, in order to help me receive medications under the Program and ensure that Program guidelines are being met;
4. Request information from my doctor, healthcare provider, or pharmacist about the prescribed medications received or will receive under the Program and about my medical condition. This information will be used only to determine my eligibility for the Program and to administer the Program. By signing below, I also authorize my doctor, healthcare provider, or pharmacist to release information about my prescribed medications and medical condition that is requested by Reach Patient Assistance, LLC or any company that Reach Patient Assistance, LLC uses to administer the Program;
5. Disclose any information obtained from the sources listed above to third parties if required by law;
6. Act in my behalf, as my attorney-in-fact, and to sign all forms and applications on my behalf and to access and release any required personal, demographic, diagnostic, therapeutic and/or financial information relating to applications for the Program.
Reach Patient Assistance, LLC
Toll-Free Phone: 1-888-727-8633
Toll-Free Fax: 1-866-727-8633
[email protected]
Toll-Free Phone: 1-888-727-8633
Toll-Free Fax: 1-866-727-8633
[email protected]
