I have read and understand the rules of the AVONEX First Month Free Trial Program on page 2 and I certify that
I am eligible to participate and that I will abide by the rules of the program. I understand that failure to comply
with these rules is a violation of federal law and may subject me to criminal and civil penalties. By signing this
authorization below, I authorize my physician to disclose to Biogen, its representatives, and third-party vendors
providing injection training (together, "Biogen"), and for Biogen to use and disclose health information relating
to my medical condition and treatment that is needed to coordinate the delivery of AVONEX to me and to arrange training on
AVONEX administration. Once my health information has been disclosed to Biogen, I understand that federal privacy laws
may no longer protect the information, however, Biogen agrees to protect my health information by using and disclosing
it only for the purposes authorized in this authorization or as required by federal law or regulations. I understand that I may
refuse to sign this authorization (but then I will not be eligible to participate in the AVONEX First Month Free Trial Program
and to receive other support services.) I may cancel this authorization at any time by mailing a letter to: Biogen Customer
Services, 5000 Davis Drive, P.O. Box 13919, Research Triangle Park, NC 27709-3919. Canceling this authorization will end further
disclosure of my health information to Biogen and my receipt from Biogen of educational and support services designed for
people taking AVONEX after the date Biogen receives my letter, but not affect Biogen's user of health information disclosed
before receipt of my letter. Canceling this authorization will not affect my ability to receive treatment with AVONEX. This authorization
expires 10 years from the day it is given.
I authorize Biogen, and companies working with Biogen, to provide me with support services related to any of Biogen's products, including but not limited to: online support, financial assistance services, compliance and persistency and other therapy support services, as well as any information or materials related to such services. I authorize Biogen, and companies working with Biogen, to contact me to provide such services and information by mail, email, fax, telephone call, text message (including calls and text messages made with an automatic telephone dialing system or a prerecorded voice), and other mutually agreed upon means. I also authorize Biogen, and companies working with Biogen, to use my health information in connection with the services, including, without limitation, sharing such information with my healthcare provider, insurance provider, or pharmacy. I also authorize the disclosure of my health information to specific individuals that I have designated.
By signing this Authorization, I authorize my healthcare provider, my health insurance company, and my pharmacy providers to disclose to Biogen, and companies working with Biogen (collectively, "Biogen"), health information relating to my medical condition, treatment, and insurance coverage for the purposes described in the Patient Services and Marketing Communications Authorization below. Once my health information has been disclosed to Biogen and/or such other individuals, I understand that federal privacy laws may no longer protect the information. However, Biogen agrees to protect my health information by using and disclosing it only for purposes authorized in this Authorization or as required by law or regulations. I understand that my pharmacy provider may receive remuneration from Biogen in exchange for the health information and/or for any therapy support services provided to me.
I understand that I may refuse to sign this Authorization. I further understand that my treatment (including with a Biogen product), payment for treatment, insurance enrollment, or eligibility for insurance benefits is not conditioned upon my agreement to sign this Authorization.
I may cancel this Authorization at any time by mailing a letter to Biogen, 5000 Davis Drive, PO Box 13919, Research Triangle Park, NC, 27709 or by visiting www.biogen.com/privacy. Canceling this Authorization will end my consent to further disclosure of my health information to Biogen and my receipt from Biogen of therapy support services, after the date that Biogen receives my letter, but will not affect information previously disclosed pursuant to this Authorization. Canceling this authorization will not affect my ability to receive treatment, payment for treatment, or my eligibility for health insurance.
This Authorization expires ten (10) years from the day I sign it as indicated by the date next to my signature unless otherwise canceled earlier as set forth above.
I authorize Biogen and its representatives to disclose and discuss my personal health information with the individuals listed below who may act on my behalf from time to time.
In addition to the individuals listed below, I acknowledge that Biogen may have to share my personal health information with my healthcare provider and government agencies or as otherwise required by law.
I may cancel this authorization or change the list of designated individuals at any time by mailing a letter expressly stating this fact to: Biogen, ATTN: Patient Services, 5000 Davis Drive, PO Box 13919, Research Triangle Park, NC, 27709. Such cancellation or change in authorization shall be effective as of the date of Biogen's receipt of my letter canceling or modifying my authorization. Canceling this authorization will not affect my ability to receive educational and other support services and information from Biogen.
© 2015 Biogen. All rights reserved.
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