Amgen’s Privacy Pledge to Patients
Amgen respects patients and customers and takes the protection of their
privacy very seriously. Amgen pledges the following:
- Amgen does not and will not sell or rent your
information to marketing companies or mailing list brokers.
- Amgen is careful to only collect and/or
use personal identifiable information for the
purposes stated in this Authorization and as necessary to provide
the services and/or programs the patient or customer chooses to
enroll into.
- Amgen practices are consistent with federal and state privacy
laws, including HIPAA.
- Amgen program enrollment is voluntary and always provides
patients with an easy
option to cancel participation.
Amgen’s Privacy Notice and Patient
Authorization
Uses and Disclosure of Personal
Information
I authorize Amgen and its contractors and business
partners (“Amgen”) to use and/or disclose
my personal information, including my personal health
information, only for the following purposes:
- To operate, administer, enroll me in, and/or continue my
participation in Nplate® Navigator 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);
- To contact, with my permission, my doctor and the rest of my health
care team and share with them my health information that may be
useful for my care;
- To provide me with informational and promotional materials
relating to Amgen products and services,
and/or my condition or treatment; and/or
- To improve, develop, and evaluate products, services, materials and
programs related to my
condition or treatment.
In order for Amgen to provide me with the services and/or
programs described above,
Amgen needs to collect and use my personal information, including my
personal health information. I
understand that my personal health information may include any
information, in electronic or physical
form, in the possession of or derived from a health care provider,
health care plan, pharmacy,
pharmaceutical company, laboratory and/or their contractor (“Health Care
Provider”). This may include
select information from or about my medical history and general health,
my health care plan benefits,
payment limits or restrictions covered by my health care plan policy,
and/or my adherence to my treatment.
I authorize my Health Care Providers to disclose my
personal health information to
Amgen, and between themselves, as necessary, but only for the purposes
stated above in this Authorization.
I understand that certain of my Health Care Providers (such as
pharmacies and specialty pharmacies) may
receive remuneration from Amgen in exchange for disclosing my
personal health information and/or for using
my information to contact me with communications about Amgen products
which have been prescribed to me (for ex. adherence programs) and other
patient support services.
Expiration, Right to Obtain a Copy and Right to
Cancel
I understand that by signing this form, I authorize my
Health Care Providers or others who
might hold my health information to only release it to Amgen employees,
as well as to its contractors and
business partners, who are performing the services set forth in this
Authorization. I also understand I am
authorizing my personal information, including my personal health
information, to be used for the purposes described above. I
understand and agree that by signing below, I am authorizing those who
rely on this Authorization to release my personal health information for
the earlier of five (5) years or until my participation in the program
ends through my cancellation, unless a shorter time period is required
by state law.
I understand that I can obtain a copy of this
Authorization or cancel this Authorization at any time by calling Amgen
at 1-844-826-7512 or by writing to Amgen P.O. Box 681308 Indianapolis,
IN 46268. If I cancel my consent, I will no longer qualify for the
services described. 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.
No Effect on Treatment
I understand I do not have to sign this Authorization and
that my enrollment in any of the services and/or programs described
above is entirely voluntary. I understand that Amgen, as well as Health
Care Providers, cannot require me, as a condition of having access to
medications, prescription drugs, treatment or other care, to sign this
Authorization. Federal Law (including HIPAA) requires a signed
authorization in order for Amgen to collect this information from my
Health Care Providers. I understand I cannot participate in the listed
services and/or programs without signing this Authorization or an
equivalent authorization with my Health Care Providers.
Information Received from Health Care
Providers
I understand that once my personal health information has
been disclosed to Amgen, federal privacy laws may no longer apply and
protect it from further disclosure. Amgen agrees, however, to protect my
personal health information by only using and disclosing it as stated in
the Authorization or as otherwise allowed or required by law. I
understand that Amgen does not and will not sell or rent my information
to marketing companies or mailing list brokers.
Authorization to Contact
I understand and consent to Amgen contacting me using the
contact information provided in this form to enroll me in, operate, and
administer Amgen patient support services and/or programs as described
above other than promotional communications by telephone or SMS/text
(which I can separately opt-in below). I understand that the operation
and administration of certain of these services and/or programs may
require that Amgen contact me by telephone or SMS/text.