I understand that by signing this form, I authorize my Health Care Personal health information and/or for using my information toĬontact me with communications about Amgen products which haveīeen prescribed to me (for example medication reminder programs)Įxpiration, Right to Obtain a Copy and Right to Cancel Receive remuneration from Amgen in exchange for disclosing my Providers (such as pharmacies and specialty pharmacies) may I understand that certain of my Health Care Health information to Amgen, and between themselves,Īs necessary, but only for the purposes stated above in thisĪuthorization. I authorize my Health Care Providers to disclose my personal My health care plan benefits, payment limits or restrictionsĬovered by my health care plan policy, and/or my adherence to my Information from or about my medical history and general health, Pharmacy, pharmaceutical company, laboratory and/or theirĬontractor (“Health Care Provider”). Of or derived from a health care provider, health care plan, Information, in electronic or physical form, in the possession I understand that my personal health information may include any Information, including my personal health information. In order for Amgen to provide me with the services and/or programsĭescribed above, Amgen needs to collect and use my personal Materials and programs related to my condition or treatment. To improve, develop, and evaluate products, services,.Relating to Amgen products and services, and/or my condition To provide me with informational and promotional materials.Health care team and share with them my health information that To contact, with my permission, my doctor and the rest of my.Verification, nurse educator services, adherence program and Programs, reimbursement assistance programs, drug coverage Related to my condition or treatment (for example, co-pay Participation in Amgen ® SupportPlus program or any otherĪmgen-affiliated patient support services and activities To operate, administer, enroll me in, and/or continue my Including my personal health information, only for the following (“Amgen”) to use and/or disclose my personal information, I authorize Amgen and its contractors and business partners They contribute $100,000 to $249,999.Uses and Disclosure of Personal Information Our Supporting partners are active champions who provide encouragement and assistance to the arthritis community. Our Signature partners make their mark by helping us identify new and meaningful resources for people with arthritis. Our Pacesetters ensure that we can chart the course for a cure for those who live with arthritis. Our Pioneers are always ready to explore and find new weapons in the fight against arthritis. These inspired and inventive champions have contributed $1,500,00 to $1,999,999. Our Visionary partners help us plan for a future that includes a cure for arthritis. Our Trailblazers are committed partners ready to lead the way, take action and fight for everyday victories. Join us today and help lead the way as a Champion of Yes. As a partner, you will help the Arthritis Foundation provide life-changing resources, science, advocacy and community connections for people with arthritis, the nations leading cause of disability.
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