Do we have your patient consent?
PATIENT CONSENT TO SHARE PROTECTED HEALTH INFORMATION (PHI) AND SIGNATURE
I authorize each of my physicians, pharmacists, including any specialty pharmacies and other healthcare providers and each of my health insurers to disclose my PHI, including but not limited to medical records, information related to my medical condition and treatment, financial, lab values, insurance coverage information, my name, address, telephone number, and last 4 digits of Social Security number to Ultragenyx Pharmaceutical Inc., and its agents, contractors, and assignees to use and disclose my PHI to enroll me in, and contact me about UltraCare Patient Services, provide case management through telephone or electronic communications to assist with adherence to my medication regimen, and work with third parties to provide community resources and referrals. Third-party vendors, such as specialty pharmacies may receive financial remuneration in exchange for data, product support services, reimbursement services, etc. This authorization expires one year from the date of execution, or one year after the date of my last prescription, whichever is later unless a shorter period is required by state law. I understand I may refuse to sign this authorization and that my treatment, payment, enrollment, or eligibility for benefits, including my access to therapy, is not conditioned on my signing this authorization. I understand that revoking this authorization will not affect the ability to use and disclose PHI received prior to receipt of notification that I wish to discontinue my participation in the program. I understand that I may revoke this authorization at any time, verbally or by writing to the address listed in this form. Once authorization has been revoked or expired, I understand my future PHI will not be disclosed. I understand that my PHI will not be used or disclosed for any other purposes, unless permitted by law, than for the purposes stated above. Information disclosed pursuant to this authorization or provided to a third party may no longer be protected by federal privacy laws. I understand that I have a right to receive a copy of this authorization.
