Patients eligible to participate in the AVONEX (interferon beta-1a) StarterONE Free Trial Program are those who are starting or restarting on AVONEX therapy. Patients who qualify will receive a 4-week supply of AVONEX delivered to their homes. The offer is not valid for patients currently on AVONEX. One AVONEX StarterONE Program Enrollment Certificate per patient will be honored. This offer is not valid for Medicare, Medicaid, or other federal healthcare program beneficiaries. This dispensed product is not for sale, trade, barter, or to be returned for credit. Neither the physician nor the patient will submit a claim to any insurer for the dispensed product or for any costs associated with this prescription, including administration. The above-named insurer may require disclosure of this certificate based on the patient's policy, and the patient will be responsible for complying with any such requirements. Completion of the AVONEX START Form is not necessary for participation in the AVONEX StarterONE Free Trial Program.
I have read and understand the rules of the AVONEX First Month Free Trial Program and 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 Idec, its representatives, and third-party vendors providing injection training (together, "Biogen Idec"), and for Biogen Idec 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 Idec, I understand that federal privacy laws may no longer protect the information, however, Biogen Idec 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 Idec Customer Services, 5000 Davis Drive, P.O. Box 13919, Research Triangle Park, NC 27709-3919. Cancelling this authorization will wend further disclosure of my health information to Biogen Idec and my receipt from Biogen Idec of educational and support services designed for people taking AVONEX after the date Biogen Idec receives my letter, but not affect Biogen Idec's user of health information disclosed before receipt of my letter. Cancelling 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 Idec 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 Idec 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 Idec, 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 Idec'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 Idec.
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