I GIVE my doctor, Emmaus Life Sciences, and the Program administrator and their employees, agents, and contractors permission to verify my information to make sure it is true and complete; contact me by mail or phone about the Program and about other products, programs, or services that might interest me or for which I may be eligible; contact me in order to ensure that I have received the medicines sent by the Program.
I ATTEST that all the information in this application, including all copies of documents proving my income, is true and complete; I am authorized to sign this application; I do not have any assistance or insurance that would help pay for my medicines; I am not enrolled in a Federal healthcare program; I will contact the Program if any of my information about my prescription drug coverage or insurance changes.
I UNDERSTAND that the Program will only use my information to decide if I qualify to participate in the Program; administer or improve the Program; communicate with insurance plans, including Medicare plans; share my information with the Centers for Medicare and Medicaid Services.
I UNDERSTAND that I may be required to apply for prescription assistance through a government assistance program to maintain eligibility in the Program.
I UNDERSTAND that I can call withdraw from the program at anytime.
I UNDERSTAND that the Program can request more information from me at any time; and ELS can change or stop the Program at any time or for any reason.
I UNDERSTAND that once my information has been disclosed to my doctor, federal privacy laws may no longer restrict its use or disclosure, but the Program will only use my information as described in this form.
I MAY refuse to sign this authorization form and I I refuse, my eligibility for health plan benefits and treatment by my healthcare provider will not change, but I will not have access to the Program.
I GIVE the Program, and the Program administrators, permission to contact the person named below with follow-up questions about my application (this only applies if someone completed this application for you). This authorization form will be effective for 1 year unless it expires earlier by law or I cancel it in writing. I have a right to receive a copy of this form after I have signed it.
I WILL notify Emmaus Life Sciences anytime there is a change in my insurance or prescription coverage.