I authorize AbbVie and its partners to use, disclose, and/or transfer the personal information I supply about myself and the patient (1) to contact me and provide me and the patient with informational and marketing materials and clinical trial opportunities related to the patient’s condition or treatment by any means of communication, including but not limited to text, e-mail, mail, or telephone; (2) to help AbbVie improve, develop, and evaluate products, services, materials, and programs related to the patient’s condition or treatment; (3) to enroll the patient in and provide the patient with HUMIRA related programs and services that I may select or refuse at any time; (4) to disclose the patient’s enrollment and use of these services to the patient’s health care providers and insurers; and (5) to use the patient’s information that cannot identify the patient for scientific and market research.

To cancel or request a copy of this authorization, please contact us at 1.800.888.6260. I understand that if I cancel, the patient may not be entitled to receive HUMIRA related programs and services.

By clicking Sign Up Now, I agree to the statements above. I also represent that I am the patient’s legal custodial parent or an authorized personal representative of the patient under applicable state law. If the patient is an unemancipated minor (generally, under 18 years of age) or otherwise does not have the capacity to enroll himself or herself into the program, the patient’s legal custodial parent or other authorized personal representative may sign the enrollment form on behalf of the patient. Only certain individuals may qualify as the patient’s personal representative (for example, an individual with a health care power of attorney or a legal guardian). State law prescribes who can be a personal representative.

I am entitled to receive a copy of my authorization and I am aware the AbbVie Privacy Statement is available at www.abbvie.com/privacy.html.