Biohaven HIPAA Authorization
Last updated: November 7th, 2022
I am electronically providing my signature indicating that I hereby authorize and request that my treating physicians, healthcare professionals, or other healthcare providers (collectively, my "Healthcare Providers") disclose and transmit my protected health information in electronic form to Biohaven and/or its designated service providers (collectively, "Biohaven") in order for Biohaven to (i) provide me, or my physician, with communications about benefits verification, my insurance plan's coverage status of prescribed Biohaven medications, Biohaven's patient affordability programs, healthcare provider educator services, and adherence programs ("Program"); (ii) operate, administer, register or enroll me in and/or provide me with access or continue access to the Program's services; (iii) identify products and services that may be of interest to me and to provide me with communications about any such products and services; and (iv) develop, evaluate and improve products, services, materials and programs related to the Program or my condition or treatment. I understand that any Healthcare Providers participating in the Program will have access to my health information as part of the Program. I request that any protected health information disclosed by my Healthcare Providers pursuant to this request is transmitted electronically to a service provider as required by the purposes stated above. This request is made pursuant to 45 CFR §164.524.
I am electronically providing my signature indicating that I have read and understood the patient authorization above, that I am legally authorized to consent, and that I am providing my consent as the patient or patient's legal guardian for Biohaven to use and share personal information I or my Healthcare Providers provide for the purposes described within this authorization. I understand the information I provide will be retained by Biohaven for at least the period of time that I am enrolled in the Program.