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Authorization Form - Upsher Smith

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Authorization Form - Upsher Smith

AUTHORIZATION FORM FOR USE AND DISCLOSURE OF PHI - UPSHER-SMITH

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Blink Health will always honor the price reflected at the time you purchased your medication. Your final price is based on the medication you pick up at the pharmacy. If you pick up a different form, dosage, or quantity, you will be charged or credited the difference. Blink Health reserves the right to cancel a transaction and refund you if the underlying cost of the prescription drug changes significantly after you have purchased your medication. Blink Health reserves the right to change its prescription drug prices in real time based on supply and demand trends and other factors. *Retail Prices (Cash Prices) vary among pharmacies. The Retail Prices displayed are estimates based on multiple sources, including price lists, historical claims and data provided by pharmacies. Our Price Match Guarantee covers generic drugs, and requires that a customer purchase at the lowest price offered by Blink (if a Blink Smart Deal is offered on a medication, the customer must purchase at the Blink Smart Deal Price). Additional conditions apply. For more details visit our Price Match page. Blink Health is not sponsored by or affiliated with any of the pharmacies identified. The pharmacy trademarks and logos above are the property of their respective owners. Blink Health is not offering advice, recommending or endorsing any specific prescription drug, pharmacy or other information. Please seek medical advice before starting, changing or terminating any medication or prescription. Disclosures: Blink Health is NOT insurance or a Medicare prescription drug plan. Users are obligated to pay the price presented during the checkout process. Blink Health is available to users at participating pharmacies only. No enrollment or periodic fees apply. Our address is 1407 Broadway, Suite 2100, New York, NY 10018, (844) 265-6444, www.blinkhealth.com.