CONSENT TO COLLECT AND USE PERSONAL HEALTH INFORMATION
Pfizer Inc. (“Pfizer”) collects certain personal health information (described below) about individuals so that it may operate a co-pay program (the “Program”). Pfizer is seeking this consent because it needs to collect, use and disclose such information, which is considered sensitive information in some states, in connection with operation of the Program.
Health Information Collected and Used. The personal health information Pfizer and its service providers collect includes name, patient identifier, test results, medical records, healthcare provider information, other data that identifies that you are seeking health care services, and data otherwise related to your health condition, diagnosis, and/or treatment (collectively “Health Information”).
Purposes of Collection and Use. Your Health Information will be used for the following purposes:
· Working with enrollee’s applicable health insurance plan to understand or verify coverage for the Program· Applying to the Program· Determining enrollee’s eligibility for and facilitating enrollment into financial assistance services if eligible, including co-pay assistance· Ensuring quality and safety and improving Pfizer’s products and services· Contacting me by various media channels with marketing related content about Pfizer’s products and services
Duration. I permit such use of my Health Information for one year after the date I sign this consent, unless and until I revoke (i.e., take back) it in writing prior to that time.
Revocation. I may revoke this consent at any time, except to the extent that Pfizer has taken any action in reliance on my consent. I understand that if I revoke this consent, it will not he any effect on any use of my Health Information that occurred prior to receiving my revocation. If I would like to revoke my approval, I may contact my physician or I may contact PAXCESS, PO Box 592188, Orlando FL 32825, M–F 9 AM–9 PM, Sat–Sun 9 AM–5 PM, and 1-877-219-7225.
I understand that this consent to collect, use and disclose my Health Information is voluntary and may be revoked in writing at any time. I further understand that not permitting the processing of my Health Information may result in my health plan or insurer not being able to participate in the Program.
I he read this consent and/or had its contents read to me. I fully understand the terms and conditions described above.