Above MS Patient Authorization

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Econsent Callout

Authorization to Share Health Information

By signing this Authorization, I authorize my healthcare provider, my health insurance company, and my pharmacy providers ("Healthcare Entities") to disclose to Biogen, and companies working with Biogen (collectively, "Biogen"), health information relating to my medical condition, treatment, and insurance coverage for Biogen to provide me with (i) support services (and related information and materials) related to any of Biogen's products, including but not limited to, online support, financial assistance services, compliance and persistency and other therapy support services, (ii) conduct data analytics, market research and other internal business activities, and (iii) information about Biogen's products, services, and programs and other topics of interest for marketing, educational or other purposes. Once my health information has been disclosed to Biogen, I understand that federal privacy laws no longer protect the information. However, Biogen agrees to protect my health information by using and disclosing it only for purposes authorized in this Authorization or as required by law or regulations. I understand that my pharmacy provider may receive remuneration from Biogen in exchange for the health information and/or for any therapy support services provided to me.

I understand that I may refuse to sign this Authorization. I further understand that my treatment (including with a Biogen product), payment for treatment, insurance enrollment or eligibility for insurance benefits are not conditioned upon my agreement to sign this Authorization; but if I do not sign it or later cancel it, I will not be able to receive Biogen Idec's therapy support services.

I may cancel this Authorization at any time by mailing a letter to: Biogen, Attn: Patient Services, 5000 Davis Drive, PO Box 13919, Research Triangle Park, NC, 27709 or visiting biogen.com/privacy. Canceling this Authorization will end my consent to further disclosure of my health information to Biogen by my Healthcare Entities after they are notified of my cancellation, but will not affect previous disclosures by them pursuant to this Authorization. Canceling this authorization will not affect my ability to receive treatment, payment for treatment, or my eligibility for health insurance.

This Authorization expires ten (10) years, or such shorter timeframe required by applicable law, from the day I sign it as indicated by the date next to my signature unless otherwise canceled earlier as set forth above.

Patient Services and Marketing/Other Communications Authorization

Patient Services

I authorize Biogen, and companies working with Biogen, to provide me with support services related to any of Biogen's products, including but not limited to: online support, financial assistance services, compliance and persistency and other therapy support services, as well as any information or materials related to such services. I agree and acknowledge that any nurse providing such support services is not employed by my healthcare professional. I authorize Biogen, and companies working with Biogen, to contact me to provide such services and information by mail, email, fax, telephone call, text message (including calls and text messages made with an automatic telephone dialing system or a prerecorded voice), and other mutually agreed upon means. I also authorize Biogen, and companies working with Biogen, to use my health information in connection with the services, including, without limitation, sharing such information with my healthcare provider, insurance provider, or pharmacy. I also authorize the disclosure of my health information to specific individuals that I have designated.

Marketing/Other Communications

I further authorize Biogen, and companies working with Biogen, to contact me by mail, email, fax, telephone call, and text message for marketing purposes or otherwise provide me with information about Biogen's products, services, and programs or other topics of interest, conduct market research or otherwise ask me about my experience with or thoughts about such topics. I understand and agree that any information that I provide may be used by Biogen to help develop new products, services, and programs. Note that Biogen will not sell or transfer your personal data to any unrelated third party for marketing purposes without your express permission. I understand that I may revoke this authorization and choose not to receive services or information from Biogen by mailing a letter to the address above or visiting biogen.com/privacy.

To authorize your consent, please sign the section below.


I have read and understand the Authorization to Share Health Information for Patient Services and Marketing/Other Communications and agree to the terms.

*Required to complete consent.

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Based on the date of birth you provided on the previous screen, you are under 18 and will need to have a parent or guardian provide an eSignature to authorize consent.


Authorization to Share Personal Health Information

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Do you wish to designate another person to give or receive confidential information on your behalf?*

If you do not wish to designate another person to give or receive confidential information on your behalf, please choose "No" and click "Submit" below.

I authorize Biogen and its representatives to disclose and discuss my personal health information with the individuals listed below.

In addition to the individuals listed below, I acknowledge that Biogen may have to share my personal health information with my healthcare provider and government agencies or as otherwise required by law.

I may cancel this authorization or change the list of designated individuals at any time by mailing a letter expressly stating this fact to: Biogen ATTN: Patient Services, 5000 Davis Drive, PO Box 13919, Research Triangle Park, NC 27709. Such cancellation or change in authorization shall be effective as of the date of Biogen's receipt of my letter canceling or modifying my authorization. Canceling this authorization will not affect my ability to receive education and other support services and information from Biogen.

Designated Individuals:

Please provide at least one designee name


Thank you for providing Above MS with this information. A Support Coordinator will follow up with you regarding the next steps in the process.