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DesignRx/DesignRxclusive LLC Discount Program Release of Information
First Name  
Last Name  
Email  
Birth Date (Format MM-DD-YYYY)  
Phone Number (Format XXX-XXX-XXXX)  


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

This release is intended to protect the privacy of your health information, yet allow the appropriate flow of information necessary to care for you. Fairview takes privacy regulations seriously and we will do our best to protect your privacy while providing you with the highest quality health care services available. Please review the Privacy Policy provided to you by DesignRx and/or DesignRxclusive, LLC for more information about how your privacy will be protected. The Privacy Policy is available at www.designrx.net.
 
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