IF YOU ARE THE PATIENT’S LEGAL REPRESENTATIVE AND NOT THE PATIENT:
PRIVACY NOTICE AND PATIENT AUTHORIZATION
By signing this Authorization, I authorize Vifor Pharma, Inc., and companies and parties working with Vifor Pharma (collectively “Vifor Pharma”), to use and/or disclose my health information about my medical
condition, records, treatment, and health plan for the purposes stated below. I also authorize my healthcare providers, my health plans, and my pharmacies to disclose my health information to Vifor
Pharma for the purposes stated below. I understand this Authorization is voluntary, but Vifor Pharma cannot provide me services and information without it.
Veltassa Konnect is a program sponsored by Vifor Pharma that provides patient support and helps eligible patients access, afford, be informed about, and comply with their treatment as prescribed. Any free
product provided through the program cannot be submitted for reimbursement and shall be used as prescribed. Once my health information has been disclosed,
I understand that privacy laws may no longer protect the information. However, Vifor Pharma agrees to protect my health information by using and
disclosing it only for purposes authorized in this Authorization or as required by law. I understand that
certain parties, such as my pharmacy provider, may receive remuneration from Vifor Pharma in connection with the activities described in this Authorization.
I authorize the use and/or disclosure of my health information for the following intended purposes only: (1) for my enrollment,
determination of my eligibility, and my participation in Veltassa Konnect (and other related patient-assistance program offerings), and for the administration of the program;
(2) to help communicate with me, my health plan, my provider, or my pharmacy about my medical care and insurance status; (3) to verify my insurance information; (4) to coordinate my prescription or
medication through my healthcare provider and provide ongoing support for my treatment as prescribed; (5) to refer me to alternative third-party patient programs; and (6) to comply with law.
I understand and agree that Vifor Pharma may contact me by mail, email, phone, and/or text. Vifor Pharma will generally leave voice messages with basic information. I authorize Vifor Pharma to leave
me voice messages with more detailed information about the reason for the call, which may contain more health information.
I understand that I may refuse to sign this Authorization and choose not to receive information or services
from Vifor Pharma. I understand that my treatment (including with a Vifor Pharma product), payment for treatment, insurance enrollment, or eligibility for insurance benefits are not conditioned upon my
agreement to sign this Authorization. I may cancel or modify this Authorization at any time by writing to Vifor Pharma at Vifor Pharma, Inc., PO Box 43848, Louisville, KY 40253. Canceling this Authorization will
end my consent after the date Vifor Pharma receives my letter but will not affect information previously disclosed pursuant to this Authorization.
This Authorization shall be in effect for five (5) years from the date of my signature, unless a shorter period is required by law or it is canceled in writing. This Authorization may be extended upon written notification
by either Vifor Pharma or myself. Upon expiration of this Authorization, all information will be destroyed.
I may receive a copy of this Authorization upon request. I certify that all the information I provide to Vifor Pharma is complete and accurate to the best of my knowledge.
I agree. By clicking the “I agree” checkbox, I electronically provide my consent and authorize Vifor Pharma and companies and parties working with Vifor Pharma
to use and/or disclose patient health information as described above. I am 18 years or older in age.
I do not agree. I do not authorize Vifor Pharma to use and/or disclose patient health information as
described above. I understand I will not be able to enroll in Veltassa Konnect.