Permissions

 

BETAPLUS, a reimbursement and clinical support program provided by Bayer HealthCare Pharmaceuticals (Bayer) for BETASERON patients. To work on your behalf, Bayer needs access to your PHI. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you must grant permission before your Protected Health Information (PHI) can be disclosed.

In order to participate in BETAPLUS, you must authorize your doctors, pharmacies, and health insurance benefit providers to share your relevant PHI with Bayer, along with certain companies that work with BETAPLUS to administer the BETAPLUS program.

By signing this form, you give Bayer and the companies it works with access to information about you, including your:

  • Name, address, and telephone number
  • Relevant medical records and financial information
  • Eligibility for assistance
  • Treatment and how it is coordinated
  • Medication and when you receive it
  • Participation in the BETAPLUS program

Your PHI will only be disclosed or shared:

  • To ensure the accuracy and completeness of this form
  • To arrange for nursing services and other ongoing support, including education, training, and communication
  • To help you with reimbursement questions
  • To see if you qualify for financial or copay assistance
  • To determine your eligibility for other programs, foundations, or alternate sources of funding to help with the costs of obtaining BETASERON
  • To communicate with you, your healthcare providers, and your insurers about your treatment with BETASERON
  • To provide information on coverage and reimbursement to your healthcare providers
  • To make relevant educational materials or product information available to you
  • To evaluate healthcare provider prescribing patterns and do other sales research
  • To comply with laws

You understand that:

  • Your PHI identifies you or could be used to identify you
  • This authorization is voluntary, and you may withdraw your authorization at any time by mailing a written request to BETAPLUS, 6251 Chancellor Drive, Suite 101, Orlando, FL 32809; or faxing your request to 1-866-248-8575
  • If you revoke this authorization, it will not affect any actions your healthcare providers or your health plan may already have taken
  • Certain healthcare providers, such as pharmacies, may receive payment from Bayer in connection with the disclosure of your PHI. They may also receive payment for using and disclosing your PHI to provide you with various communications
  • Persons or entities that receive your PHI under this authorization may not be required by privacy laws (such as HIPAA) to protect the information and may share it with others without your permission, if permitted by the laws that apply to them
  • This authorization expires at the end of your participation in the Program or five (5) years after you sign it, whichever comes first
  • Your medical treatment, payments, insurance enrollment, or eligibility for insurance benefits do not depend on your signing this form
  • If you do not sign this form, you will not receive assistance through BETAPLUS

By signing up below, I acknowledge that I have read this authorization, or had it read to me, in its entirety. I authorize the use and disclosure of my Protected Health Information (PHI) as described in this form. I understand that I am entitled to receive a signed copy of this authorization.

Please read our Privacy Policy for more information.

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