AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Last updated: November 7th, 2022
I authorize KMG Medical Group MO, P.C., its affiliated entities, and its management company Thirty Madison, Inc. (“Provider”) to disclose my protected health information (“PHI”) to Biohaven Pharmaceutical Holding Company Ltd. (“Manufacturer”) and any of Manufacturer’s agents or contractors, including but not limited to ClaritasRx (“Contractors”), for purposes of enrolling me in and/or providing me with access or continued access to the the Nurtec ODT Patient Savings Program (the “Purpose”).
I understand and agree that the following PHI may be disclosed to the Manufacturer and its Contractors for this Purpose:
- Full Name
- Date of Birth
- Phone Number
- Patient ID #
- Email Address
- Copay Card ID #
I understand that I may refuse to agree to the terms in this form. My Provider will not condition my general treatment on my agreeing to the terms in this authorization form; however, my Provider will not be able to enroll me in the Nurtec ODT Patient Savings Program unless I agree to the terms in this authorization form.
I further understand: - I can revoke this authorization at any time by submitting a request to email@example.com. My revocation will not apply to PHI that was already disclosed pursuant to this authorization. - Unless I revoke this authorization earlier, this authorization will expire one (1) year from the date on which I accept these terms.
- Once my PHI is disclosed pursuant to this authorization, it may not be protected by any federal or state privacy regulations and may be redisclosed by the Manufacturer and/or its Contractors. - I can obtain a copy of this authorization by downloading/printing this form from www.withcove.com or by submitting a request to firstname.lastname@example.org.
By clicking “I agree,” I acknowledge that I have read and understand the terms of this authorization, and I agree to its terms. I release the Provider, its employees, officers and directors, and business associates from any legal responsibility or liability for the disclosure of PHI to the extent indicated and authorized herein.