PatientAssistanceProgramApplication:AuthorizationforDisclosureofInformationIunderstandthatthepurposeofthisauthorization(“Authorization”)istogivemypermissionforthedisclosureanduseofmyprotectedhealthinformation.Irequestandauthorizemyhealthcareprovidersandhealthcareinsurersthathaveprovidedtreatment,paymentorservicestomeorformetodiscloseanyinformationregardingmyhealth,treatment,andcoveragethatpertainstopaymentformedicationtotheAbbViePatientAssistanceFoundation,AbbVieInc.,itsaffiliates,orthirdpartiescontractedbytheAbbViePatientAssistanceFoundation,(collectively,the“Foundation”)forthefollowingpurposes:(i)todeterminemyeligibilityfortheFoundation’spatientassistanceprogram(“PAP”),(ii)ifnecessary,toaccountforandassistwithmywithdrawalfromthePAPand/ortransfertoaseparateprivateorpublicpayerprogram,and(iii)toadministerandmaintainthehighqualityofthePAP,includingbutnotlimitedtocasereview,compliancechecks,auditreview,accountingpurposes.IunderstandthatoncetheFoundationreceivesmyhealthinformation,itmaycommunicatewithmyhealthcareprovidersandinsurerstodeterminemyPAPeligibility.IunderstandthatIamnotrequiredtosignthisAuthorizationandthatnohealthcareproviderorinsurerwillconditiontreatment,payment,enrollmentoreligibilityforbenefitsonwhetherIsignthisAuthorization.However,IunderstandthatifIdonotsignthisAuthorization,IcannottakepartinthePAP(shouldIqualify).IunderstandthatImaycancelthisauthorizationatanytimebywritingtotheAbbViePatientAssistanceFoundationatD-617927,AP5NE,1N.WaukeganRd.NorthChicago,IL,60064aswellasbynotifyingmyhealthcareprovidersandinsurers.IfIcancelthisAuthorization,IcannolongerparticipateincertainaspectsofthePAP.OncetheFoundationreceivesandprocessesmycancellationrequest,theFoundationwillnotusemyhealthinformationgoingforward.IunderstandthatcancellingmyAuthorizationwillnotaffectanyuseofmyhealthinformationthatoccurredbeforemyrequestwasprocessed.Thisauthorizationshallbevalidfor10yearsfromthedateofthesignatureonthisform(unlessashorterperiodisprescribedbystatelaw).Iunderstandthat,unlessotherwiserestrictedbystatelaw,myhealthinformationreleasedunderthisAuthorizationissubjecttore-disclosurebytheFoundationandwillnolongerbeprotectedbyHIPAA.