By signing below, I authorize my child’s healthcare providers and staff, pharmacies, and health insurers to use and to disclose to Sobi, Inc., and its affiliates, business partners, vendors, and other agents (collectively, “Sobi”) health information about my child related to my child’s medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for SYNAGIS (“Information”) to (1) enroll my child in and provide services under the SYNAGIS CONNECT™ patient support program (the “Program”); (2) obtain information on my child’s insurance coverage; (3) coordinate prescription fulfillment as indicated by my child’s physician; (4) provide me with adherence reminders and support; and (5) contact me to conduct market research and to arrange for my receipt of educational, promotional, and/or marketing materials about Sobi support programs or Sobi products. Once my child’s Information has been disclosed to Sobi, I understand that federal privacy laws may no longer protect it from further disclosure. However, I also understand that Sobi will protect my child’s Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law.
I understand and agree that the pharmacy that dispenses SYNAGIS may receive payment from Sobi in exchange for disclosing my child’s Information to Sobi and providing Program services.
I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my child’s ability to obtain medical treatment from healthcare providers, payment for treatment or eligibility for health insurance benefits, or access to Sobi medications. However, if I do not sign this Authorization, I understand my child will not be able to participate in the Program.
I understand that this Authorization expires ten years from the date signed below, or earlier if required by state or local law, unless and until I cancel (take back) this Authorization before then. I may change my mind and cancel this Authorization at any time by calling 1-833-SYNAGIS (1-833-796-2447) or by notifying Sobi in writing at SYNAGIS CONNECT, PO Box 29076, Phoenix, AZ 85038-9076. Cancellation of this Authorization will end further uses and disclosures of my child’s Information by my child’s healthcare provider and staff, pharmacies, and health insurers based on this Authorization, and my child’s participation in the Program when they receive notice of my cancellation, but will not affect any uses or disclosure of my child’s Information made by my child’s healthcare providers and staff, pharmacies, and health insurers based on this Authorization before receipt of the cancellation.