I understand that the purpose of this authorization (“Authorization”) is to give my permission for the disclosure and use of my protected health information to the extent it is required under state and federal law. I hereby authorize my healthcare providers, healthcare insurers, and laboratory testing facilities that have provided treatment, payment, or services to me or for me (collectively, "Healthcare Companies") to disclose information about me, my medical condition, and my treatment, insurance coverage and payment information in relation to my use of AbbVie products (collectively, "Personal Information") to AbbVie, its affiliates, and agents/contractors (“AbbVie Partners”), in order for AbbVie and AbbVie Partners to use and disclose my Personal Information: (1) to provide me with HUMIRA related programs and services (“HUMIRA Services”); (2) to contact me about and provide me with informational and marketing materials and related to my condition or treatment by any means of communication; and (3) to help AbbVie internally improve, develop, and evaluate products, services, materials, programs, and treatment related to my condition or treatment. I understand that once AbbVie and the AbbVie Partners receive my Personal Information, they may communicate with my Healthcare Companies to provide the HUMIRA Services. AbbVie and the AbbVie Partners are hereby notified by the Healthcare Companies that they may use the disclosed Personal Information only for the purposes set forth above. I also understand that if my Healthcare Companies use or disclose my Personal Information for marketing purposes, they may receive financial remuneration.
I understand that I am not required to sign this Authorization and that my Healthcare Companies will not condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this Authorization. I understand that this Authorization will expire in 10 years or a shorter time period if required by state law, unless I cancel it sooner. However, I understand that if I do not sign this Authorization, I cannot participate in certain HUMIRA Services. I may cancel my Authorization by calling 800.888.6260 and by notifying my Healthcare Companies. Once AbbVie receives and processes my cancellation request, AbbVie will not use my Personal Information going forward. I understand that cancelling my Authorization will not affect any use of my Personal Information that occurred before my request was processed. I understand that my Personal Information released under this Authorization is subject to re-disclosure by AbbVie and AbbVie Partners and will no longer be protected by HIPAA.
California, Rhode Island, Minnesota and Florida Only: State law prohibits the person receiving my Personal Information from making further disclosure of it, unless another authorization for such disclosure is obtained from me or unless such disclosure is required or permitted by law. I expressly agree to enter into this Authorization in electronic format and to the use of affirmatively checking the box below as my electronic signature. By signing below, I agree to the statements above and that I am currently 18 years of age or older.
