I authorize my health plans, physicians, and pharmacies (my "Providers") to disclose my personal health and insurance information ("PHI") to Acorda Therapeutics, Inc. and its agents (the "Entities") in order to (1) provide services to me by Prescription Support Services; (2) facilitate the provision of products, supplies or services by Acorda; (3) register me in any applicable Acorda product registration program; (4) evaluate the effectiveness of Acorda's INBRIJA education programs; (5) enroll me in Acorda's patient assistance program, copay mitigation program, or similar programs which may be deployed by Acorda (if one or more such programs apply to me); and (6) facilitate the provision of information and training to me by third parties regarding the use of INBRIJA and its inhaler device. I understand my pharmacies will disclose personal health information resulting in remuneration to my pharmacies. I understand that once my PHI is disclosed under this authorization, it is no longer protected by Federal privacy laws and could be further disclosed. I understand that I may refuse to sign this authorization and my healthcare provider(s) and health plan(s) will not condition my treatment or benefits on whether I sign this authorization, but if I do not sign this authorization, I may not be able to receive assistance through Prescription Support Services. I understand that I am entitled to a copy of this authorization. I understand that I may cancel this authorization at any time by mailing a letter requesting such cancellation to Acorda Therapeutics, Inc., 9801 Washingtonian Boulevard, Gaithersburg, MD 20878 but that this cancellation will not apply to any information already used or disclosed pursuant to this authorization before notice of the cancellation is received by each of the Entities. This authorization expires 10 years from the date of execution or upon such earlier date as may be mandated by state law, if applicable....See More
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