Upsher-Smith Patient HIPAA Authorization
Want additional help obtaining coverage for your medication?
Upsher-Smith Laboratories (the manufacturer of your medication) offers an optional program for patients and their providers to help you obtain coverage for certain Upsher-Smith medications.
By clicking “I consent” below, you are providing a valid signature that authorizes Blink Health Pharmacy LLC and its affiliates (together, “Blink”) to use and share Protected Health Information (“PHI”) with Upsher-Smith Laboratories and its affiliates and contractors (together, “Upsher-Smith”) so that they can work with your healthcare providers to help you obtain coverage for your prescription.
Type of Information Authorized to be Disclosed: I authorize Blink Health to disclose the following types of protected health information to Upsher-Smith:
- your name, prescription records, information about your health insurance and benefits, and other information about your health.
I Am Not Required to Sign this Authorization. You do not have to give permission to share your PHI with Upsher-Smith in order to receive your prescription or other treatment from Blink and obtain your lowest prescription price. However, Upsher-Smith may not be able to provide you with additional coverage assistance without it.
Expiration Date: This authorization to use and share your PHI lasts for three (3) years from the date below, unless a shorter period is required by law.
Right to Revoke Authorization: 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 firstname.lastname@example.org. Any revocation will not apply to PHI used or shared prior to the time Blink Health receives your notice of revocation.
My Information May Be Re-Disclosed: Blink may be remunerated by Upsher-Smith in exchange for sharing your PHI with Upsher-Smith 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. Upsher-Smith recognizes that your PHI is sensitive and is committed to protecting it and keeping it confidential.
Right to Receive Copy of This Authorization. You are entitled to a copy of this authorization and can request a copy by emailing email@example.com.
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I have read and consent to this Patient HIPAA Authorization.