Legally Authorized Representative
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Access 360™ Patient Authorization
By completing this registration,
I authorize my health care providers (HCPs) and staff, my health plan, an 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; to 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 porpuses 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 1-844-275-2360. 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 below 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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By pressing submit,
you will receive information about your disease and may receive information about other AstraZeneca medicines and services related to your condition.
AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and Programs.
AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If in the future you no longer want to receive health-related materials, call 1-800-236-9933. Please visit
to review our Privacy Notice.