Want additional help obtaining coverage for your medication? Shield Therapeutics (the manufacturer of your medication) offers an optional program for patients and their providers to help you obtain coverage for certain Shield Therapeutics medications.
By clicking “I consent” below, you are providing a valid signature that authorizes BlinkRx LLC and its affiliates (together, “Blink”) to use and share Protected Health Information (“PHI”) with Shield Therapeutics plc and its affiliates and contractors (together, “Shield Therapeutics”) so that they can work with your healthcare providers to help you obtain coverage for your prescription. This PHI includes your name, prescription records, information about your health insurance and benefits, and other information about your health.
You do not have to give permission to share your PHI with Shield Therapeutics in order to receive your prescription or other treatment from Blink and obtain your lowest prescription price. However, Shield Therapeutics may not be able to provide you with additional coverage assistance without it.
This authorization to use and share your PHI lasts for three (3) years from today's date, unless a shorter period is required by law. You may revoke this authorization in writing at any time by mailing a letter requesting such revocation to Blink Health, Attn: Privacy Officer, 1407 Broadway, Suite 1910, New York, NY, or via email to email@example.com. Any revocation will not apply to PHI used or shared prior to the time Blink Health receives your notice of revocation. Blink may be remunerated by Shield Therapeutics in exchange for sharing your PHI with Shield Therapeutics or using your PHI to provide services. After your PHI is shared, it may no longer be protected by applicable federal privacy laws, and the person or entity that receives your PHI may not be prevented from further disclosing your information. Shield Therapeutics recognizes that your PHI is sensitive and is committed to protecting it and keeping it confidential. You are entitled to a copy of this authorization and can request a copy by emailing firstname.lastname@example.org.
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I have read and consent to this Patient HIPAA Authorization.