MANNKIND'S COMMITMENT TO YOU
• We do not and will not sell or rent your information to marketing companies or mailing list brokers
• We will only collect and use personally identifiable information for the purposes stated in this Authorization and as necessary to provide the services and/or programs into which each patient or customer chooses to enroll
• Your enrollment and authorization is completely voluntary and can be cancelled at any time
• We take seriously our obligation to comply with state and federal laws that protect your personally identifiable information, including your personal health information
Uses and Disclosure of Personal Information
I authorize MannKind and its contractors and business partners (“MannKind”) to use and disclose my personal information, including my personal health information (“PHI”), only for the following purposes:
• To operate, administer, enroll me in, and/or continue my participation in MannKind’s V-Go Cares program or any other MannKind-affiliated patient support services and activities related to my condition or treatment (e.g., co-pay card programs, reimbursement assistance programs, drug coverage verification, product training programs);
• To contact me by mail, email, SMS/text message, facsimile, telephone, and other means to enroll me in and administer patient support programs and services and to provide me with free educational information and materials;
• To communicate with my doctor and the rest of my healthcare team and receive from and share with them my health information that may be useful for my care and to facilitate requested patient support services;
• To provide me with informational and promotional materials relating to MannKind products and services, and/or my condition or treatment; and
• To improve, develop, and evaluate products, services, materials, and programs related to my condition or treatment.
Notification of Use and Signature
In order for MannKind to provide me with patient support services and/or programs, MannKind needs to collect and use my personal information, including my PHI.
I understand that my PHI may include any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company, laboratory and/or their contractor (“Health Care Provider”). This may include select information from or about my medical history and general health, my health care plan benefits, payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment.
I authorize my Health Care Providers to disclose my PHI to MannKind, and between themselves, as necessary, but only for the purposes stated above in this Authorization.
Expiration, Right to Obtain a Copy and Right to Cancel
I understand that by signing this form, I authorize my Health Care Providers, or others who might hold my health information to only release it to MannKind employees, as well as to its contractors and business partners performing the services set forth in this Authorization. I also understand I am authorizing my personal information, including my PHI, to be used for the purposes described above.
I understand and agree that by signing below, I am authorizing those who rely on this Authorization to release my PHI for the earlier of five (5) years or until my participation in the program ends through my cancellation, unless a shorter time period is required by state law.
I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling MannKind at 1-844-622-7371, or by writing to 30930 Russell Ranch Road, Suite 300, Westlake Village CA, 91362. If I cancel my consent, I will no longer qualify for the services described. I also understand that if a Health Care Provider is disclosing my PHI to MannKind on an authorized on-going basis, my cancellation with MannKind will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation.
No Effect on Treatment
I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely voluntary. I understand that MannKind, as well as Health Care Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment or other care, to sign this Authorization. Federal Law (including HIPAA) requires a signed authorization in order for MannKind to collect this information from my Health Care Providers. I understand I cannot participate in the listed services and/or programs without signing this Authorization or an equivalent authorization with my Health Care Providers.
Information Received from Health Care Providers
I understand that once my PHI has been disclosed to MannKind, federal privacy laws may no longer apply and protect it from further disclosure. MannKind agrees, however, to protect my PHI by only using and disclosing it as stated in the Authorization, or as otherwise allowed or required by law.
Authorization to Contact
I understand and consent to MannKind contacting me using the contact information provided in this form to enroll me in, operate, and administer the services described above. I understand that the operation and administration of these services and/or programs may require that MannKind contact me by telephone or SMS/text and that my cell phone carrier’s standard rates may apply for calls or text messages to my cell phone.
This Authorization and related documents may be signed electronically. If signing electronically, by typing your name in the signature section of this page, you agree that you are signing this document. You understand that your electronic signature is legally binding, just as if you signed a paper document, and you acknowledge that you have read and understand this Patient Authorization Form.
By signing below, I am providing my consent and indicating my legal authorization for MannKind and its contractors and business partners to use and share the personal information I give only for the purposes described within this Authorization.