By signing this Authorization, you agree to permit the Authorized Parties listed below to
disclose Protected Health Information (PHI) about you to Alexion Pharmaceuticals, Inc. for
the uses described more fully below.
THE AUTHORIZED PARTIES INCLUDE:
(1) Your primary care physician, evaluating and/or treating physician, and any specialist or other
healthcare providers involved in your treatment (“Providers”); (2) the distributor, pharmacy, or home health
agency that dispenses your medical therapy (“Distributors”); and (3) your health insurer, payor, or patient
assistance program (“Payors”).
The PHI (“Information”) that may be disclosed includes medical reports, orders, prescriptions and records,
histories, findings, prognoses, plans of care and discharge summaries, billing information, insurance
claims, and utilization review reports.
The Authorized Parties may disclose this Information to Alexion Pharmaceuticals
Corporation, including, but not limited to, its employees, sub-contractors, agents, and other
representatives (together, “Alexion”), so that Alexion may use and disclose the Information for the
1. Coordination of Care: Between you, the Providers, Distributors, or Payor for the
coordination of your medical care.
2. Disease Management/Patient Education: To provide information, training, and case
management services to you (or your
representative), and any Providers, Payor, and
3. Clinical Research/Treatment Protocols: To inform you (or your representative) of
clinical research studies, treatment protocols,
or disease-related surveys that may benefit you.
4. Reviewing Your Insurance Benefits/Plan and/or Funding Options: To review, verify, and
to assist you in
benefits provided by
your Payor, to verify
what services your
benefits cover and help
you obtain the services
ordered by your
Provider, to coordinate
benefits, to determine
appeal requirements, and
to identify other
sources of payment, if
5. Billing and Payment: To coordinate the preparation, filing, and processing of health
insurance claims, the evaluation of coding (billing) issues, and
assist with the resolution of any claims issues relating to your
6. Distribution of Hematologic Therapy: To coordinate the distribution of medical therapy
7. Product Orders: To fulfill any product orders and answer any questions that you may
provide to the Alexion call center, and otherwise to inform you about
other services that may be of interest to you.
8. Government Agencies: To provide information as required or requested by representatives
of government agencies, review boards, and others who watch over
the safety of drugs (or operations) of pharmaceutical
9. Other Use of Information: To de-identify the information about you and to use this
de-identified information in performing clinical research,
patient and community education, clinical protocol
development, marketing studies, or for other commercial
purposes as determined by Alexion.
10. Contact: To contact you or your authorized representative (if designated above) by
mail, e-mail, or telephone.
Once your Information has been disclosed to Alexion, federal privacy laws may no longer protect it from
further disclosure. However, Alexion agrees to protect your Information by using and disclosing it only for
the purposes described in this Authorization or as permitted by law.
You do not have to sign this Authorization. If you do not sign this Authorization, or choose to revoke it,
your ability to obtain medical care and/or therapy, or your eligibility or enrollment for insurance benefits
will not be affected. However, if you do not sign this Authorization, Alexion will not be able to provide
the services described above.
This Authorization shall remain in effect until January 1, 2020 unless it is revoked (taken back) by you.
You may revoke this Authorization at any time by sending a written letter which includes your name and
address, to Alexion Pharmaceuticals, Inc. at the address or fax on the top of this form. You have the right
to receive a copy of this Authorization upon request.