By submitting this form, I agree that I understand the information below and authorize Fairview Pharmacy Services LLC to release my protected health information as indicated.
Important Information About Your Health Information
This form requires your consent in order for you to participate in a discount program made available to you through Fairview Pharmacy Services, LLC.
DesignRx and DesignRxclusive
DesignRx and DesignRxclusive LLC negotiate discount contracts with pharmaceutical and/or device manufacturers for products used for treatment of fertility disorders. In exchange for discounts, available to you by signing up for the service, the above companies provide market information to the manufacturers. DesignRx and DesignRxclusive LLC do not share your protected health information with the manufacturers.
Release of Information
- These discount programs are not a healthcare benefit. If you chose to enroll in a discount program, we need your approval to send information about your prescription to DesignRx or DesignRxclusive, LLC depending on the discount you wish to access.
- DesignRx and DesignRxclusive have additional terms of confidentiality in their programs. The manufacturer will not contact you directly regarding your prescription.
- DesignRx or DesignRxclusive will include you in e-mail messaging (or by mail if you do not have an e-mail address) about additional services that may be of interest to you as part of your membership in their programs. You are free to opt out of this program at any time.
By submitting this form, you acknowledge that the discount drug you receive is not being covered as part of your health benefit plan. You also authorize Fairview Pharmacy Services, LLC to share your protected health information with DesignRx and DesignRxclusive, LLC in order to facilitate the discount offered. You authorize DesignRx and/or DesignRxclusive, LLC to contact you by e-mail (or mail of you do not have an e-mail address) about additional services offered by DesignRx and/or DesignRxclusive that may be of interest to you. You have the right to revoke this authorization at any time by notifying Fairview Pharmacy Services, LLC and DesignRx and DesignRxclusive, LLC in writing, and if you do, it will not have any effect on any actions DesignRx and DesignRxclusive, LLC took before it received the revocation of this release.
For more information about Fairview’s privacy practices