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. 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.
I understand that once my PHI has been disclosed to MannKind, federal privacy laws may no longer apply and protect it from further disclosure. Information Received from 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. Federal Law (including HIPAA) requires a signed authorization in order for MannKind to collect this information from my Health Care Providers. 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. 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 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. If I cancel my consent, I will no longer qualify for the services described. I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling MannKind at 1-84, or by writing to 30930 Russell Ranch Road, Suite 300, Westlake Village CA, 91362.
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 also understand I am authorizing my personal information, including my PHI, to be used for the purposes described above. 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 authorize my Health Care Providers to disclose my PHIto MannKind, and between themselves, as necessary, but only for the purposes stated above in this Authorization.Įxpiration, Right to Obtain a Copy and Right to Cancel 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 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”). 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. To improve, develop, and evaluate products, services, materials, and programs related to my condition or treatment.
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