AUTHORIZATION FORM FOR USE AND DISCLOSURE OF PHI
By clicking “consent” below, I am authorizing Blink Health Pharmacy LLC (“Blink Health”) to disclose protected health information about me to:
Amarin Pharma, Inc., and its vendors, affiliates, and subsidiaries (collectively, Amarin).
Purpose of Disclosure: I understand that my information will be disclosed to Amarin for the following purposes:
- To send me offers, products, and services from Amarin or third parties that may be of interest to me; To allow Amarin to improve its products and services, by, among other things performing data analytics; and
- To provide me with customer service related to patient assistance programs for Vascepa sponsored by Amarin.
I understand that Blink Health may receive payment or other remuneration for protected health information provided to Amarin, in exchange for obtaining this authorization, or making communications to be that are described in this authorization.
Type of Information Authorized to be Disclosed: I authorize Blink Health to disclose the following types of protected health information to Amarin:
- My demographic information: First Name, Last Name, and Email Address, Mailing Address, City, State, Zip Code and Phone Number
- My prescription information related to Vascepa
Right to Revoke Authorization: I understand that I have the right to revoke this authorization by clicking the "Unsubscribe" link provided in any email or text message I receive from Blink Health. My revocation will not be effective for uses and disclosures of my information that occurred prior to the processing of my revocation for this authorization.
My Information May Be Re-Disclosed: I understand that if my protected health information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the person or entity who receives my protected health information and may no longer be protected by applicable privacy laws.
I Am Not Required to Sign this Authorization. I understand that I may refuse to sign this authorization and that Blink Health will not condition treatment, payment, or enrollment or eligibility for benefits on whether I sign this authorization.
Right to Receive Copy of This Authorization. I understand that if I agree to sign this authorization, which I am not required to do, I have a right to receive a signed copy of the form. For a copy of this authorization, please contact email@example.com.
EXPIRATION DATE: This authorization will expire upon [insert date 1 year from my date of consent] unless I revoke it sooner, or a shorter period is required by applicable law.
BY CLICKING "I CONSENT", YOU ARE CONFIRMING: THIS AUTHORIZATION ACCURATELY REFLECTS YOUR WISHES WITH RESPECT TO THE USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION, YOUR AGREEMENT TO SIGN THIS AUTHORIZATION ELECTRONICALLY, YOUR AGREEMENT TO RECEIVE ONLY AN ELECTRONIC COPY OF THIS AUTHORIZATION, AND IF YOU ARE ACTING AS THE PATIENT’S PERSONAL REPRESENTATIVE, YOUR AUTHORITY TO ACT ON BEHALF OF PATIENT