PATIENT HIPAA AUTHORIZATION FOR SANTEN SERVICES (Read/scroll
through entire content below to continue)
I hereby authorize my healthcare providers, my health insurance
company, and my pharmacy to disclose my protected health
information (PHI) including, but not limited to, my name, address,
telephone number, medical records, health insurance coverage, and
financial information to Santen Incorporated and companies working
with Santen Incorporated (collectively “Santen Incorporated”) and
its agents for the following purposes:
Contact me, or the person legally authorized to sign on my
behalf, by phone or mail for Santen PASS purposes
I authorize calls/texts may mention the name of Santen products
or services, details about my insurance coverage and my doctor’s
name. I understand that I am not required to consent to being
contacted by phone or text message as a condition of any purchase
of Santen products or enrollment. Message and data rates may
apply. I understand that I may opt out of receiving these
communications at any time by calling Santen PASS
Contact my insurance company on my behalf to verify my coverage
for Verkazia 1 mg/mL eye drops
Determine my eligibility, and enroll in the Commercial
Copay/Coinsurance Assistance Program
Determine my eligibility, and enroll in the Patient Assistance
Program (PAP), including verification of my financial information
Coordinate my treatment with my healthcare provider and
specialty pharmacy
Send me educational materials or other program information that
may be of interest to me
Send reminders about refilling medication for adherence support
I understand that Santen Incorporated may offer an ongoing
customized patient support program. The support program could
include a care coordinator contacting me by telephone, email, or
text to provide ongoing personalized support over a period of time.
Once my health information has been disclosed to Santen
Incorporated, I understand that federal privacy laws may no longer
protect the information. However, I understand that Santen
Incorporated and other companies authorized to receive my health
information pursuant to this authorization agree 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 this authorization does not affect
treatment from my healthcare provider or coverage for Verkazia
1 mg/mL eye drops through my insurance.
I understand that this authorization is voluntary. However, if I
refuse to sign, or cancel my authorization, Santen Incorporated
may not be able to determine my eligibility for the Commercial
Copay/Coinsurance Assistance Program or the Patient Assistance
Program (PAP). I may cancel this authorization at any time by
mailing a letter to PO Box 5490, Louisville, KY 40255. This
authorization expires five [5] years from the day that I sign it
as indicated by the date next to my signature, unless (i) otherwise
canceled as set forth above, (ii) the patient reaches the age of
majority, or unless (iii) a shorter period is mandated by the law
of my state of residence. I understand that canceling this
authorization is not effective to the extent that any person or
entity has already acted in reliance on my authorization.
I understand that my pharmacy, health insurers, and third-party
vendors may receive remuneration (payment) from Santen
Incorporated in exchange for disclosing my personal information to
Santen Incorporated and/or for providing me with support services
for the purposes described above.
I understand and have read this authorization. I understand that
I am entitled to receive a signed copy of this form and can do so
by calling Santen PASS at 1-833-577-PASS (7277) or by mailing a
request to the address above.
I agree with these terms and
conditions
