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  • Health Insurance Portability and Accountability Act ("HIPAA")

    I hereby authorize BioPlus Specialty Pharmacy Services, Inc. ("BioPlus"), and its agents and employees, to release medical information and other information pertaining to the health and condition of the above-identified Patient.

    This authorization applies to the following recipients:

    To drug and pharmaceutical manufacturers and patient assistance programs (and their respective agents) which offer financial assistance to patients for the cost of medications. The purpose of this disclosure is to facilitate and obtain payment and payment assistance for medication and treatment, where available. To the manufacturer/distributor of the Patient's medication or course of treatment (and their agents). The purpose of this disclosure is to coordinate the care and provision of such medications, and track and monitor medication interactions and reactions.

    I authorize BioPlus to release the entire, unredacted records, pursuant to 45 CFR § 164.508 (HIPAA Authorization Requirements for Release of Protected Health Information), to the extent necessary to meet the purpose of the disclosures.

    This authorization expires when my treatment or course of medications facilitated through BioPlus is complete.

    I understand that the information disclosed under this authorization may be re-disclosed by the recipients, and may no longer be subject to the same protections the information is given by BioPlus.

    I understand that I may revoke this authorization at any time as explained by BioPlus in its Notice of Privacy Practices, except to the extent that action has already been taken in reliance upon this authorization.

    I understand that I have the right to refuse to sign this authorization. I understand that BioPlus may not condition the provision of treatment or payment based on my refusal to sign this authorization.

    I hereby release BioPlus from any and all liability in connection with the disclosure of records and information pursuant to this Authorization. This authorization also includes the authority to copy and inspect any and all such information and to discuss the information with the above designated entities.

  • Medical Record Number - Optional