Patient HIPAA Authorization
By signing the Patient Authorization section of this EntyvioConnect Enrollment Form, I authorize my physician, health insurance, and pharmacy providers (including any specialty pharmacy that receives my prescription) to disclose my protected health information, including, but not limited to, information relating to my medical condition, treatment, care management, and health insurance, as well as all information provided on this form (“Protected Health Information”), to Takeda Pharmaceuticals U.S.A., Inc. and its present or future affiliates, including the affiliates and service providers that work on Takeda's behalf in connection with the EntyvioConnect Patient Support Program (the “Companies”). The Companies will use my Protected Health Information for the purpose of facilitating the provision of the EntyvioConnect Patient Support Program products, supplies, or services as selected by me or my physician and may include (but not be limited to) verification of insurance benefits and drug coverage, prior authorization education, financial assistance with co-pays, patient assistance programs, and other related programs. Specifically, I authorize the Companies to 1) receive, use, and disclose my Protected Health Information in order to enroll me in EntyvioConnect and contact me, and/or the person legally authorized to sign on my behalf, about EntyvioConnect; 2) provide me, and/or the person legally authorized to sign on my behalf, with educational materials, information, and services related to EntyvioConnect; 3) verify, investigate, and provide information about my coverage for ENTYVIO, including but not limited to communicating with my insurer, specialty pharmacies, and others involved in processing my pharmacy claims to verify my coverage; 4) coordinate prescription fulfillment; and 5) use my information to conduct internal analyses.
I understand that employees of the Companies only use my Protected Health Information for the purposes described herein, to administer the EntyvioConnect Patient Support Program or as otherwise required or allowed under the law, unless information that specifically identifies me is removed. Further, I understand that my healthcare provider may receive financial remuneration from Takeda Pharmaceuticals U.S.A. for marketing services. I understand that Protected Health Information disclosed under this Authorization may no longer be protected by federal privacy law. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization and that instructions for doing so are contained in Takeda's Website Privacy Notice. I understand that such cancellation will not apply to any information already used or disclosed through this Authorization. This Authorization will expire within five (5) years from the date it is signed, unless a shorter period is provided for by state law. I understand that I may refuse to sign this Authorization and that refusing to sign this Authorization will not change the way my physician, health insurance, and pharmacy providers treat me. I also understand that if I do not sign this Authorization, I will not be able to receive EntyvioConnect Patient Support Program products, supplies, or services.
EntyvioConnect Patient Support Program Enrollment
EntyvioConnect Patient Support Program Enrollment Terms and Conditions
Enroll me in the EntyvioConnect Patient Support Program (the “Program”). I have read and understand the applicable terms and conditions. I certify that all the information provided on this form is accurate and complete, and I agree to notify the Program immediately if my medical or prescription drug coverage changes in any way. I understand that Takeda and its business partners will use my personal information to enroll me in the Program, provide the support I am asking for, and offer related services to me. I authorize Takeda, its affiliates and business partners to use my personal information to provide me with information and offers related to ENTYVIO, the diseases and the conditions it treats, and related treatment options. In addition to information about ENTYVIO and related health conditions, I understand this may include information about clinical trials and market research opportunities, and other support services or programs Takeda may in the future develop for patients. I also authorize Takeda to use my de-identified information to help Takeda improve and develop products, services, materials, and programs or for health economic outcomes and market research. I understand that I may revoke my permission at any time. To learn how Takeda will use and protect my personal information, I acknowledge that I have reviewed Takeda's Privacy Notice.
I have read, understand, and agree to the use of my personal information for the purposes described above.
Signature must match First Name and Last Name you provided previously: