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PATIENT AUTHORIZATION AND CONSENT - …
Page 1 of 3P-BAG-US-00223 EXPIRY February 2020 PATIENT AUTHORIZATION AND CONSENTTO COMPLETE THIS FORM:PO Box 29297 | Phoenix, AZ 85039 Phone: 844-INSPPRT (844-467-7778) Fax: 844-814-0669 the Terms and Conditions and the PATIENT Certification for the Copay Assistance Program on page 2, if the PATIENT AUTHORIZATION and CONSENT Form on page 3. At the top of the form, provide your name, the name of your healthcare professional (HCP), and your INSUPPORT Case ID (if provided by your HCP) Complete any optional sections of the form, if desired Read, sign, and date the bottom of the form3 Submit the completed PATIENT AUTHORIZATION and CONSENT Form (page 3 only) to INSUPPORT via fax at 844-814-0669, or the INSUPPORT PATIENT Portal at Inc. reserves the right to cancel, revoke, or change any service that INSUPPORT provides as they choose without prior : RISK OF SERIOUS HARM OR DEATH WITH INTRAVENOUS ADMINISTRATION; SUBLOCADE RISK EVALUATION AND MITIGATION STRATEGY Serious harm or death could result if administered intravenously.
Page 3 of 3 P-BAG-US-00223 EXPIRY February 2020 Fax INSUPPORT: 844-814-0669 X Patient Signature Date By signing below, • I authorize 1. my treatment provider (including his/her staff and any affiliated group practices), 2. the health insurer(s) listed on my enrollment form, and 3. the specialty pharmacy that dispenses SUBLOCADE to me to …
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