I. Authorization to Share Health Information
I understand that I have certain rights related to the collection, use, and disclosure of [my/my child’s] medical and health information. This information is called “protected health information” (PHI) and includes demographic information (such as sex, race, date of birth, etc.), the results of physical examinations, clinical tests, blood tests, X-rays, and other diagnostic medical procedures that may be included in [my/my child’s] medical records. Biogen will not use [my/my child’s] PHI without my consent.
By signing this Authorization, I authorize [my/my child’s] healthcare provider, [my/my child’s] health insurance company and [my/my child’s] pharmacy providers (“Healthcare Entities”) to disclose to Biogen, and companies working with Biogen (collectively, “Biogen”), health information relating to [my/my child’s] medical condition, treatment, and insurance coverage for Biogen to (i) provide [me/my child] with support services (and related information and materials) 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, and (ii) conduct data analysis, market research and other necessary internal business activities, and (iii) provide me with information about Biogen’s products, services, and programs for educational or other purposes. I understand that once I sign this Authorization, and [my/my child’s] medical and health information is disclosed to Biogen by the Healthcare Entities, the Health Insurance Portability and Accountability Act (HIPAA) will no longer protect my information because Biogen is not covered by HIPAA. However, Biogen agrees to protect [my/my child’s] 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/my child’s] pharmacy provider may receive remuneration from Biogen in exchange for the health information and/or for any therapy support services provided to [me/my child].
I understand that I may refuse to sign this Authorization. I further understand that [my/my child’s] treatment (including with a Biogen product), payment for treatment, insurance enrollment or eligibility for insurance benefits are not conditioned upon my agreement to sign this Authorization; but if I do not sign it or later cancel it, [I/my child] will not be able to receive Biogen’s therapy support services.
I may cancel this Authorization at any time by mailing a letter to: Biogen, ATTN: Patient Services, 5000 Davis Drive, Morrisville, NC, 27560 or emailing privacy@biogen.com. Canceling this Authorization will end consent to further disclosure of [my/my child’s] health information to Biogen by [my/my child’s] Healthcare Entities after they are notified of my cancellation but will not affect previous disclosures by them pursuant to this Authorization. Canceling this authorization will not affect [my/my child’s] ability to receive treatment, payment for treatment, or [my/my child’s] eligibility for health insurance.
This Authorization expires ten (10) years, or such shorter timeframe required by applicable law, from the day I sign it as indicated by the date next to my signature unless otherwise canceled earlier as set forth above.
I have read and understand the Authorization to Share Health Information and agree to the terms.
Please type your name below to provide your signature to authorize the
consent:
(If the patient is a minor and you are the
patient's Parent/Legal Guardian, please type in your name.)
II. Patient Services Authorization
By signing this Authorization, I authorize Biogen, and companies working with Biogen, to provide [me/my child] 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 understand and agree that personnel, including but not limited to nurses, providing such support services on behalf of Biogen are not employed by [my/my child’s] healthcare professional. 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), chat, push notifications and other forms of electronic messaging.
I also authorize Biogen, and companies working with Biogen, to use and disclose [my/my child’s] medical and health information in connection with providing the services, including but not limited to, disclosing [my/my child’s] information to vendors, processors, and service providers for business purposes associated with providing the services, sharing such information with [my/my child’s] healthcare provider, insurance provider, or pharmacy, or disclosing [my/my child’s] information where required by applicable laws or regulations. I also authorize the disclosure of [my/my child’s] health information to specific individuals that I have designated.
I have read and understand the Patient Services Authorization and agree to the terms
Please type your name below to provide your signature to authorize the
consent:
(If the patient is a minor and you are the
patient's Parent/Legal Guardian, please type in your name.)
III. Marketing Authorization
By checking the “Agree to terms” box, I authorize Biogen, and companies working with Biogen, to contact me by mobile or online digital media, mail, email, fax, telephone call, and text message (including autodialed and prerecorded calls and messages) for marketing purposes or otherwise provide me with information about Biogen’s products, services, and programs or other topics of interest, conduct market research or otherwise ask me about [my/my child’s] experience with or thoughts about such topics. I understand and agree that any information that I provide may be used by Biogen for marketing, including targeted online marketing, as well as to develop new products, services, and programs. I understand that Biogen will not sell or transfer [my/my child’s] personal data to any unrelated third party for marketing purposes without my express permission. I understand that my consent is not required as a condition of purchasing or receiving any goods or services from Biogen. I understand that I may revoke this authorization and choose not to receive information from Biogen by sending an email with the subject “Unsubscribe” to privacy@biogen.com, or mailing a letter to Biogen, 5000 Davis Drive, Morrisville, NC 27560. For more information visit biogen.com/privacy.
- Home Phone :
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Residents of certain US States (including but not limited to California) may have additional rights regarding the collection, use, maintenance, disclosure, and deletion of your personal information. To understand or exercise those rights California residents please visit https://www.biogen.com/privacy-center.html.
I understand that I have the right to receive a copy of the terms and conditions of my agreement with Biogen, and that I may request that copy at the time of signing or at a later date by contacting Biogen at: Biogen, ATTN: Patient Services, 5000 Davis Drive, Morrisville, NC, 27560 or emailing privacy@biogen.com.
