I understand I do not have to sign this AuthorizationĪnd that my enrollment in any of the services and/or

I also understand that if a Health Care Provider is disclosing my personal health information to Amgen on an authorized on-going basis, my cancellation with Amgen will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation. If I cancel my consent, I will no longer qualify for the services described. I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen SupportPlus at 1-833-44AMGEN (1-83) or by writing to PO BOX 2135, Morristown, NJ 07962-9927. Through my cancellation, unless a shorter time Or until my participation in the program ends Health information for the earlier of five (5) years Rely on this Authorization to release my personal That by signing below, I am authorizing those who Personal health information, to be used for the I also understand IĪm authorizing my personal information, including my Health information to only release it to AmgenĮmployees, as well as to its contractors andīusiness partners, who are performing the services My Health Care Providers or others who might hold my I understand that by signing this form, I authorize Medication reminder programs) and other patientĮxpiration, Right to Obtain a Copy and Right to Which have been prescribed to me (for example

Information and/or for using my information toĬontact me with communications about Amgen products Specialty pharmacies) may receive remuneration fromĪmgen in exchange for disclosing my personal health Health Care Providers (such as pharmacies and Necessary, but only for the purposes stated above in Information to Amgen, and between themselves, as Health Care Providers to disclose my personal health Restrictions covered by my health care plan policy,Īnd/or my adherence to my treatment. My health care plan benefits, payment limits or This may include select informationįrom or about my medical history and general health, Provider, health care plan, pharmacy, pharmaceuticalĬompany, laboratory and/or their contractor ('HealthĬare Provider'). Possession of or derived from a health care Information, in electronic or physical form, in the Personal health information may include any In order for Amgen to provide me with the servicesĪnd/or programs described above, Amgen needs toĬollect and use my personal information, including Services, materials and programs related to my To improve, develop, and evaluate products,.Products and services, and/or my condition or Them my health information that may be useful The rest of my health care team and share with To contact, with my permission, my doctor and.To operate, administer, enroll me in, and/or continue my participation in Amgen ® SupportPlus program or any other Amgen-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs, reimbursement assistance programs, drug coverage verification, nurse educator services, adherence program and disease management support).Information, only for the following purposes: Personal information, including my personal health Partners (“Amgen”) to use and/or disclose my I authorize Amgen and its contractors and business To treat moderate to severe chronic plaque psoriasis (PsO) inĪdults who are ready for systemic therapy or phototherapy, and are under the care ofĪ doctor who will decide if other systemic therapies are less appropriate.Is not known if adalimumab products are effective in people who stopped responding to orĬould not tolerate TNF-blocker medicines. To treat moderate to severe ulcerative colitis (UC) in adults.To treat moderate to severe Crohn’s disease (CD) in adults and children 6 years of age and older.Moderate to severe hidradenitis suppurativa (HS) in adults.AMJEVITA may prevent further damage to yourīones and joints and may help your ability to perform daily activities. AMJEVITA can be usedĪlone or with certain other medicines. AMJEVITA can be used alone or with methotrexate. Moderate to severe polyarticular juvenile idiopathic arthritis (JIA) in children 2 years of age and older.Moderate to severe rheumatoid arthritis (RA) in adults.ĪMJEVITA can be used alone, with methotrexate, or with certain other medicines.ĪMJEVITA may prevent further damage to your bones and joints and may help your.AMJEVITA is a prescription medicine used:

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