Authorization to Use and Disclose Personal Health Information and to Conduct Patient Support
I authorize my health plans, physicians, pharmacies, and other healthcare providers (collectively, my “Providers”) to disclose my personal health information relating to my use of KYNMOBI (apomorphine HCl) sublingual film, including my medical condition, treatment, care management, as well as the information provided on this form (collectively, “Personal Health Information” or “PHI”), to Sunovion Pharmaceuticals Inc. and its representatives, agents, and contractors that act on behalf of Sunovion (collectively, “Sunovion”) so that Sunovion may use the information to enroll me in (including verifying my eligibility, as applicable), facilitate my participation in, and administer KYNMOBI™ KYNNECT and any other applicable KYNMOBI patient support programs that may be implemented by Sunovion (collectively, “KYNMOBI Patient Support”). As part of this, Sunovion may use and disclose my Personal Health Information to:
Provide all KYNMOBI Patient Support for which I am eligible and have not opted out of and, where applicable, as prescribed by my doctor or other healthcare provider;
Communicate with my Providers and other third parties as needed to facilitate the provision of KYNMOBI Patient Support;
Contact me and my designated representative(s) regarding this form and my enrollment and participation in KYNMOBI Patient Support, and provide me with related patient support communications, including by mail, email, fax, telephone call, voicemail, text message (including calls and text messages made with an automatic telephone-dialing system or a prerecorded voice) (up to 5 messages per week) (standard message and data rates may apply; you may opt out at any time by replying “STOP”) and through messages left for me that disclose that I take or may take KYNMOBI;
Provide me with educational information about KYNMOBI, in person, online, or by telephone, including information and training regarding my use of KYNMOBI;
Monitor and evaluate KYNMOBI Patient Support for effectiveness, future program development, and other administrative purposes; and
Monitor and report safety information about KYNMOBI, including in communications with the US Food and Drug Administration and other government authorities.
I understand that once my Personal Health Information is disclosed to Sunovion under this authorization, it is no longer protected by federal privacy laws and may be further disclosed by Sunovion. 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 Patient Authorization. I understand, however, that if I do not sign this authorization, I may not be able to receive support through KYNMOBI™ KYNNECT. 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 Sunovion Pharmaceuticals Inc., 84 Waterford Drive, Marlborough, MA 01752, but that this cancellation will not apply to any information already used or disclosed pursuant to this authorization before the notice of the cancellation is received by Sunovion. This authorization expires ten (10) years from the date of execution or upon such an earlier date as may be mandated by state law, if applicable.
We look forward to telling you more about KYNMOBI, a new medication to treat OFF episodes associated with Parkinson's disease, as it becomes available.
If you no longer wish to receive email communications about KYNMOBI, please enter your email address below* and then click “Submit.” Your email address will be removed from our mailing list.
Please allow 7-10 days to process your request.
*Certain health plans do not cover, or participate in, this service. Check with the health plan for further details. Walgreens Express is available on eligible prescriptions only. Most prescription orders are available to be delivered to the patient’s home in 1–2 business days. Orders received by 4pm on Friday, as well as requests made during the weekend, have an expected delivery day of Wednesday. Prescriptions are not delivered on Sundays or holidays. Please note that while most prescriptions are expected to be delivered in 1–2 business days, some deliveries may not be eligible for delivery due to prescription type, delivery address, holidays, weather, or other delivery constraints.
†Participating patients agree not to submit claims to, or seek reimbursement from, any third-party payer for the product; Medicare Part D patients must opt out of Part D coverage for the product for the remainder of the plan year and agree not to count the purchase of the product toward their Medicare Part D TrOOP. Participating patients agree to notify their Medicare Part D plan or other third party payor, as applicable, that they are participating in the offering.
‡Up to a maximum of 5 cartons per 30-day prescription.