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Thank you for you interest in Biogen Support Service. In order for Biogen to provide you with educational and product support services for your prescribed therapy, it is necessary that you first complete and sign this patient authorization form. Upon receiving this patient authorization form, Biogen will be allowed to provide you with support services and to use your personal health information to provide these services.
If you do not wish to consent for this purpose, do not sign this form. Please understand that by not agreeing to the terms in the Authorization to Share Health Information and Patient Services Authorization sections, Biogen will not be able to provide you with therapy support services.
You may always call us with any questions about the patient authorization form.
I understand that I have certain rights related to the collection, use, and disclosure of my 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 medical records. Biogen will not use my PHI without my consent.
By signing this Authorization, I authorize my healthcare provider, my health insurance company, and my pharmacy providers ("Healthcare Entities") to disclose to Biogen, and companies working with Biogen (collectively, "Biogen"), health information relating to my medical condition, treatment, and insurance coverage for Biogen to (i) provide me 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, (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 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 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 are not conditioned upon my agreement to sign this Authorization; but if I do not sign it or later cancel it, I 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, PO Box 13919, Research Triangle Park, NC, 27709 or emailing privacy@biogen.com. Canceling this Authorization will end my consent to further disclosure of my health information to Biogen by my 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 ability to receive treatment, payment for treatment, or my 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.
*Required to complete consent.
By signing this authorization, 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 understand and agree that personnel including but not limited to nurses, providing such support services on behalf of Biogen are not employed by my 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 and push notifications and other forms of electronic messaging.
I also authorize Biogen, and companies working with Biogen, to use and disclose my medical and health information in connection with providing the services, including but not limited to, disclosing my information to vendors, processors, and service providers for business purposes associated with providing the services, sharing such information with my healthcare provider, insurance provider, or pharmacy, or disclosing my information where required by applicable laws or regulations. I also authorize the disclosure of my health information to specific individuals that I have designated.
I have read and understand the Patient Services Authorization and agree to the terms.
To authorize your consent, please sign the section below.
*Required to complete consent.
By selecting "Yes" below, I authorize Biogen, and companies working with Biogen, to contact me by mail, email, fax, telephone call, and text message 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 experience with or thoughts about such topics.
I understand that Biogen may use auto-dialers, prerecorded messages and artificial voice messages to contact me at the telephone number I have provided on this form and that my mobile provider may charge me to receive these messages. I understand and agree that any information that I provide may be used by Biogen for marketing purposes, including targeted online marketing, as well as to help develop new products, services, and programs. I understand that Biogen will not sell or transfer my personal information to any unrelated third party for marketing purposes without my express permission. I understand that my consent to receive marketing communications 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 services or information from Biogen by mailing a letter to the address above or sending an email with the subject "Unsubscribe" to privacy@biogen.com.
I have read and understand the Marketing Authorization and I agree to the terms.
I consent to have Biogen contact me for marketing purposes via the phone number and email address provided below.
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/california-policy.html. For more information, 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, PO Box 13919, Research Triangle Park, NC, 27709 or emailing privacy@biogen.com.
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Do you wish to designate another person to give or receive confidential information on your behalf?*
If you do not wish to designate another person to give or receive confidential information on your behalf, please choose "No" and click "Submit" below.
I authorize Biogen and its representatives to disclose and discuss my personal health information with the individuals listed below.
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 may change the list of designated individuals at any time by calling Patient Services at 800-456-2255 or 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 phone call or letter canceling or modifying my authorization. Canceling this authorization will not affect my ability to receive education and other support services and information from Biogen.