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.