By clicking submit, I authorize each of my prescribers, pharmacists, including any specialty pharmacy that receives my prescription for CRYSVITA® (burosumab-twza) and other healthcare providers (together “Healthcare Providers”) and each of my health insurers (together, “Insurers”) to disclose my Protected Health Information, including but not limited to medical records, information related to my medical condition and treatment, my health insurance coverage, my name, address, telephone number, Social Security number, insurance plan and or group numbers (together, “Protected Health Information”) to Kyowa Kirin, its affiliated companies, vendors, agents, collaboration partners, and representatives (together, “Kyowa Kirin”) including providers of alternate sources of funding for prescription drug costs, and other service providers supporting Kyowa Kirin Cares Support Services (the “Program”) for Healthcare Providers and patients for the purposes described below.
Specifically, I authorize disclosure of my Protected Health Information in order to:
I. Enroll me in, and contact me about the Program, including online support, financial assistance services, co-pay assistance, specialist services, and compliance and persistency servicesII. Communicate with my Healthcare Providers and Insurers about benefits, coverage and medical care, including compliance with Product treatmentsIII. Locate a specialty pharmacy that can fill my prescription and facilitate dispensing of my prescription by such pharmacyIV. Provide me with educational materials, information and services related to my treatment experience with CRYSVITA and my conditionV. Contact me and leave messages about my use of CRYSVITA and my medical careVI. Verify, investigate, assist with, and coordinate my coverage for CRYSVITA with my InsurersVII. Coordinate prescription fulfillmentVIII. Conduct surveys, data analytics, market research and other internal business activities related to the Program, CRYSVITA, and other Kyowa Kirin products and programsIX. Contact me as otherwise required or permitted by lawI understand that pharmacies that ship my medication may be paid to share this information with the Program to help provide the offerings requested for me. Once my Protected Health Information has been disclosed to Kyowa Kirin, I understand that federal privacy laws no longer protect the information. However, Kyowa Kirin agrees to protect my Protected Health Information by using and disclosing it only for the purposes described in this Authorization or as permitted by law.
I understand that I may refuse to sign this Authorization. My choice about whether to sign will not change the way my Healthcare Providers or Insurers treat me, but I will not have access to the Program and the services provided by Kyowa Kirin under the Program. If I refuse to sign the Authorization, or revoke my authorization later, I understand that this means I will not be able to participate or receive assistance from the Program.
This Authorization will last for a period of five (5) years (unless earlier termination is required by applicable state law). I understand that I may cancel this Authorization at any time in the future, except to the extent that actions have been taken in reliance
on the Authorization, by mailing a request to 212 Carnegie Center Dr, Suite 400, Princeton, NJ 08540, via fax at 833-552-3299, or by calling 833-552-2737. I understand that revoking this Authorization will end further uses and disclosure of my Protected
Health Information by the parties identified above except to the extent those uses and disclosures have been made in reliance upon this Authorization as permitted by applicable law. I am entitled to receive a copy of this Authorization.
The personal information and health insurance I have provided on this form is complete and accurate to the best of my knowledge. I will update my information promptly if any of the information reflected on this form changes by contacting the Program at 833-552-2737.
Please provide a signature to acknowledge this form.
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