Step 1 of 3 33% Health Insurance Portability and Accountability Act ("HIPAA")Authorization for Release of Medical Information I hereby authorize BioPlus Specialty Pharmacy Services, Inc., and their network of pharmacies, MedScripts Medical Pharmacy, River Medical Pharmacy, and Route 300 Pharmacy (the "BioPlus Pharmacies"), and their agents and employees, to use and disclose prescription, insurance, diagnosis and other information pertaining to the health and condition (the "Information") of the identified patient ("Patient"). I authorize the Information to be disclosed among the BioPlus Pharmacies and to drug manufacturers, patient assistance programs, and research organization ("Designees") and their respective agents. The authorized purposes for such use or disclosure are to provide Patient with and coordinate Patient's healthcare; provide Patient with reimbursement support and healthcare product and service offerings; or for BioPlus Pharmacies' or Designees' analysis of business processes, disease therapy treatment, or drug therapy treatment. I acknowledge that the BioPlus Pharmacies may receive payment from third parties for such use or disclosure of the Information. This authorization expires 4 years from the date of my signature or when my treatment or course of medication facilitated through a BioPlus Pharmacy is complete, whichever occurs first. I understand that the information disclosed under this authorization may be re-disclosed by the recipients, and may no longer be subject to the same protections the information is given by the BioPlus Pharmacies. I understand that I may revoke this authorization at any time by sending written notification to Privacy Officer, Bioplus Specialty Pharmacy 376 Northlake Blvd Altamonte Springs, FL 32701, except to the extent that action has already been taken in reliance upon this authorization. I understand that I have the right to refuse to sign this authorization. I understand that BioPlus Pharmacies may not condition the provision of treatment or payment based on my refusal to sign this authorization. MRN#Medical Record Number - OptionalPatient Name* First Last Patient Signature*Former/Alias/Maiden Name (if applicable):Date of Birth* Date Format: MM slash DD slash YYYY Name of Personal Representative (If Applicable) First Last Signature of Personal Representative (If Applicable)Description of Personal Representative’s Authority Therapy Consent This acknowledges that my physician has prescribed medication(s) for me and that BioPlus Specialty Pharmacy Services, Inc. and their network of pharmacies MedScripts Medical Pharmacy, River Medical Pharmacy or Route 300 Medical Pharmacy (each “Pharmacy”) will serve as the medical pharmacy. The route of administration of this medication is indicated on the medication prescription label along with directions for use. I understand that I have pharmacy options available. I acknowledge that my therapy is under the control of my physician; I select and authorize Pharmacy to furnish the medications and supplies deemed necessary to administer my therapy as ordered by my physician. My physician has explained my therapy and treatment to me, alternate therapies available, and the substantial risks and hazards inherent with this therapy. I understand that there may be special instructions or training. I agree to read the instructions and complete any training necessary. I agree to abide by the instructions and training provided. I understand all aspects of my home self-care and understand that I have the right to ask any questions and receive answers during my participation in the program. I have been instructed to call “911” for emergency medical attention. I have received information regarding biomedical waste disposal, emergency preparedness and drug information. I have received a copy of the Patient’s Rights and Responsibilities and a copy of the Notice of Privacy Practices, and I understand these documents. I further know that any time I have questions, I can call the pharmacy at 1- 866-514-8082. Various drug manufacturers and other entities offer patient assistance programs that provide payment assistance, including without limitation co-pay cards, or cost reductions for certain therapies, prescriptions, and medications. I authorize Pharmacy to take all necessary actions to enroll and register me in applicable patient assistance programs for which I am qualified for the purposes of identifying and obtaining such payment support. Because I am receiving specialty medications, Pharmacy is required by contract to obtain proof of delivery. I understand that I will be asked to sign for my delivery via the delivery carrier. If I am unable to sign for the delivery, I will sign and return the packing ticket enclosed with my shipment. If you have insurance coverage provided through any type of state-, federal-, or government-funded programs, (Medicare, Medicaid, Federal Employees Health Benefits, TRICARE, VA), you are not eligible to participate in the Co-pay Program. I attest that my insurance plan is not a state or federal government insurance plan, such as Medicare, Medicaid, or Tricare. Calls to the pharmacy may be recorded for training, record keeping and quality assurance purposes. If your prescription drug coverage is provided by a private commercial payer and the commercial payer has opted out of the Co-pay Program, you are not eligible to participate. I understand it is my responsibility to verify with my insurance plan any limitations they may have for the use of copay cards or other assistance I may use. I shall not accept any copay card or other assistance if prohibited by my insurance plan. Please contact the pharmacy at 1- 866-514-8082 with any questions regarding this form. Financial Assistance**I authorize BioPlus to enroll and register me in applicable patient assistance programs..I DO NOT authorize BioPlus to enroll and register me in applicable patient assistance programs.Required** I have read and fully understand this consent to therapy. IF YOU ARE ON INFUSION THERAPY PLEASE READ THE INFO BELOW If I am an infusion patient, I understand that there are additional risks associated with the use of intravenous medication and my physician has educated me about those risks. If my therapy requires an electronic or mechanical pump, it will be sent and indicated on my delivery ticket and will be accompanied by an operating instruction manual along with information about any applicable warranties. I acknowledge that I have received information, such as an equipment warranty information form and/or a warranty information page in my operating instruction manual, about any warranties that may cover the pumps, devices, and other items supplied to me. Furthermore, the product is being sold or leased to me by BioPlus as a service for my convenience. I understand further that any and all representations regarding the equipment are the responsibility of the manufacturer and its authorized agents (including, but not limited to distributors and authorized service technicians). I have received instructions on the operating and related minor maintenance of the equipment and have read the operating instructions all of which are, in my opinion, adequate to enable me to properly operate it without direction of professional support staff at BioPlus. I understand that, to the maximum extent permissible under law, BioPlus shall not in any event be liable for any consequential damages, secondary charges, lawsuits, or damages resulting from an alleged defect of the equipment or disposable supplies. A home health nurse may operate this infusion device and I will follow his or her instructions. If I am a Medicare beneficiary, I understand that BioPlus honors all warranties expressed and implied under applicable State law and will not charge me or the Medicare program for the repair or replacement of Medicare covered items (including all purchased and capped rental items and other rented items) or services covered under warranty. My physician has explained that there are risks, known and unknown, associated with the use of all medical equipment and supplies used with the administration of medication, and because I will be using the equipment and/or supplies at home, immediate emergency medical attention will probably not be available for any complication, injuries or adverse results that may occur in connection with using the equipment or supplies.Required for Infusion Therapy Patients* I am on INFUSION THERAPY and have read and fully understand this consent to therapy. Assignment and Designation of Authorized Representative Considering the amount of medical expenses to be incurred, I, the undersigned, state that I have health insurance and/or employee health care benefits that will pay for the health care to be provided by BioPlus Specialty Pharmacy Services, Inc. and their network of pharmacies MedScripts Medical Pharmacy, River Medical Pharmacy or Route 300 Medical Pharmacy (each “Pharmacy”). I give Pharmacy all the rights I have for health care to be paid for through insurance and/or though my employee health care benefit plan (self-insured or fully-insured), this document is a designation of authorized representation and an assignment to Pharmacy of my right to health insurance and/or health care benefits (self-insured or fully-insured). The details of this authorized representation and assignment are set forth below. I hereby assign and convey directly to Pharmacy, as my assignee and designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, devices, and/or medications rendered or provided by Pharmacy, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize Pharmacy to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named health care provider any and all employee benefit Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named health care provider or its attorneys in order to claim such medical benefits. In addition to the assignment of the medical benefits and/or insurance and/or plan reimbursement above, I also assign and/or convey to Pharmacy any legal, equitable or administrative claim or chose in action arising under any group health plan, employee benefits plan (self-insured or fully-insured), health insurance or tort feasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, devices and/or medications I receive from Pharmacy (including any right to pursue those legal, equitable or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA1 breach or fiduciary duty claims and other legal and/or administrative claims. I intend by this assignment and designation of authorized representative to convey to Pharmacy all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the above-named health care provider, including rights to any settlement, insurance or applicable legal, equitable, or administrative remedies (including damages, remedies, and civil penalties arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (Pharmacy) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan (self-insured or fully-insured), health care benefit plan, or plan administrator. Pharmacy as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense. This assignment is irrevocable and valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare, and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original. 1ERISA is an acronym for a federal law entitled the Employee Retirement Income Security Act. ERISA governs most group health benefits provided by employee benefit plans. A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise. Most private sector health plans are covered by ERISA. Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law. Required** I have read and fully understand this agreement This iframe contains the logic required to handle Ajax powered Gravity Forms.