Fillable Enrollment Form - First Steps (Page 2 of 2) in pdf

General Authorization to Use and Disclose Health and Other Personal Information

I, _______________________________________________, or my personal representative, hereby authorize my

physician and his/her staff to disclose my health and other personal information, including, but not limited to, the

information on this form, to DesignRx, LLC and its agents and representatives including any company that helps

administer the DesignRx Assist Program (collectively “DesignRx”) so that DesignRx may use and further disclose my

information to healthcare providers, pharmacies, insurance companies, prescription drug plans and other third-party

payers (collectively, “Third Parties”) in order to:

(1) contact me about participating in the DesignRx Assist Program;

(2) provide me with materials relating to the DesignRx Assist Program;

(3) verify the accuracy of the information I provide in my application for the DesignRx Assist Program;

(4) provide support services that can assist me with obtaining access to the DesignRx Assist Program products;

(5) for such other purposes as may be required or permitted by applicable law.

I further authorize the Third Parties to disclose health and other personal information about me in their possession to

DesignRx in order to assist DesignRx in accomplishing the purposes described above.

I do not authorize the use or disclosure of any information relating to sexually transmitted disease, acquired

immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), mental health or substance abuse.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no

longer be protected by federal and/or state privacy laws. However, I understand that DesignRx will not release my

information to any party, except as provided in this authorization or as permitted by applicable law, without first obtaining

my (or my authorized personal representative’s) separate written consent.

I understand that I am not required to sign this authorization and such refusal will not affect my ability to receive DesignRx

Program products, my ability to obtain treatment, or my eligibility for benefits but it will limit my ability to participate in the

DesignRx Assist Program.

I understand that this authorization will remain in effect for one year from the date of my signature, unless I revoke it

earlier in writing by mailing my revocation to DesignRx, LLC/EnvisionRxOptions, 2181 East Aurora Road, Suite 201,

Twinsburg, OH 44087, via facsimile at 855-672-9262, or via email at .

If I revoke this authorization, DesignRx will stop using and disclosing my information once it is received and logged by

DesignRx. I understand that any use or disclosure made prior to the revocation of this authorization will not be affected by

the revocation nor will the revocation apply to disclosures made in reliance on this authorization. I understand that

revoking my authorization will also limit my ability to participate in the DesignRx Assist Program.

A copy of this authorization is valid as an original. I also understand that I have the right to receive a copy of this

authorization.

Patient name (please print): _____________________________________________ Date: ___/___/______

Signature of patient (or personal representative): ____________________________

Printed Name and Authority/relationship of personal representative (if applicable):

___________________________________________________________________

DesignRx.GenAuthDisclosure.10.29.2013

Enrollment Form - First Steps Page 2