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Access 360 Patient Authorization
By completing this registration,
I authorize my health care providers (HCPs) and staff, my health plan, and my pharmacies to use and share Protected Health Information (my “Information”) with AstraZeneca (including Access 360) and its affiliates, as well as its contractors (“AstraZeneca”).
My Information includes my prescription-related health records, Information about my health care plan benefits, demographic, contact, and any other Information bearing on my health. My Information may be used to verify treatment and payment decisions with my HCPs; investigate and assist with coordination of coverage for AstraZeneca products; coordinate prescription fulfillment and financial assistance; and perform internal analysis at AstraZeneca to better meet patient needs. I understand and agree that AstraZeneca may contact me by mail, email, and telephone.
I understand that federal privacy laws may not protect my Information once it is disclosed; however, AstraZeneca agrees to protect my Information by using and disclosing it only for purposes specified. I understand that I can refuse to sign this Authorization and that this will not affect my treatment or payment for treatment, insurance coverage, or eligibility for benefits. However, if I do not sign this Authorization, I will not be able to receive Access 360 support. I understand that I may cancel this Authorization at any time by calling 1-833-360-HELP or by mailing a letter requesting such cancellation to Access 360 at One MedImmune Way, Gaithersburg, MD 20878. I understand that any such cancellation will not apply to any Information already used or disclosed based on this Authorization prior to their receipt of the cancellation.
This authorization expires two (2) years from the date signed, unless a shorter period is required by state law.
By clicking Submit,
I affirm that I am authorized to sign this form and that my electronic signature on this form has the same effect as my written signature. In the event I encounter difficulty in obtaining a copy of this form, I understand I may call 1-844-ASK-A360 (1-844-275-2360) for assistance.
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