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Authorization for Release of Health Information

I understand that the purpose of this authorization (“Authorization”) is to give my permission for the disclosure and use of my protected health information to the extent it is required under state and federal law. I hereby authorize my healthcare providers and healthcare insurers that have provided treatment, payment, or services to me or for me (collectively, "Healthcare Companies") to disclose information about me, my medical condition, and my treatment, insurance coverage and payment information in relation to my use of AbbVie products (collectively, "Personal Information") to AbbVie, its affiliates, and agents/contractors (“AbbVie Partners”), in order for AbbVie and AbbVie Partners to use and disclose my Personal Information: (1) to provide me with insurance coverage information and associated programs and services information related to AndroGel 1.62% (“AndroGel 1.62% Services”); and (2) to help AbbVie internally improve, develop, and evaluate products, services, materials, programs, and treatment related to my condition or treatment. I understand that once AbbVie and the AbbVie Partners receive my Personal Information, they may communicate with my Healthcare Companies to provide the AndroGel 1.62% Services. AbbVie and the AbbVie Partners are hereby notified by the Healthcare Companies that they may use the disclosed Personal Information only for the purposes set forth above.

I understand that I am not required to sign this Authorization and that my Healthcare Companies will not condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this Authorization.

I understand that this Authorization will expire in 10 years or a shorter time period if required by state law, unless I cancel it sooner. However, I understand that if I do not sign this Authorization, I cannot participate in certain AndroGel 1.62% Services. I may cancel my Authorization by calling 855-498-0162 and by notifying my Healthcare Companies. Once AbbVie receives and processes my cancellation request, AbbVie will not use my Personal Information going forward. I understand that cancelling my Authorization will not affect any use of my Personal Information that occurred before my request was processed.

I understand that my Personal Information released under this Authorization is subject to re-disclosure by AbbVie and AbbVie Partners and will no longer be protected by HIPAA.

California, Rhode Island, Minnesota and Florida Only: State law prohibits the person receiving my Personal Information from making further disclosure of it, unless another authorization for such disclosure is obtained from me or unless such disclosure is required or permitted by law.

I expressly agree to enter into this Authorization in electronic format and to the use of affirmatively checking the box online as my electronic signature. By signing, I agree to the statements above and that I am currently 18 years of age or older.

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USE: AndroGel® (testosterone gel) 1% and 1.62%

AndroGel® (testosterone gel) 1% and 1.62% are controlled substances, available by prescription, used to treat adult males who have low or no testosterone due to certain medical conditions. It is not known if AndroGel is safe or effective to treat men who have low testosterone due to aging. It is not known if AndroGel is safe or effective in children younger than 18 years old. Testosterone products that are applied to the skin may have different doses, strengths, or application instructions that may lead to different levels of testosterone in your body.

Important Safety Information

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088or call 1-800-FDA-1088.

If you cannot afford your medication, contact www.pparx.org for assistance.

Click here for Use and Important Safety Information.

References: 1. AndroGel 1.62% [package insert]. North Chicago, IL: AbbVie Inc. 2. AndroGel 1% [package insert]. North Chicago, IL: AbbVie Inc.