Thank you for completing this form. The information you provide allows CutisCo Dermatology to work with your insurance company, specialty pharmacy, pharmacy benefit manager (PBM), and medication manufacturer to help obtain timely access to your prescribed medication.

When appropriate, this authorization also allows us to enroll you in manufacturer-sponsored patient support programs that may provide copay assistance, financial assistance, bridge medication, patient education, and other services related to your treatment. A list of Patient Enrollment forms can be found here.

Completion of this form takes approximately 5–10 minutes. Please have your insurance card available before you begin.

I authorize CutisCo Dermatology, its physicians, advanced practice providers, employees, contractors, agents, and authorized representatives to use, disclose, obtain, receive, and exchange my protected health information (PHI), insurance information, demographic information, prescriptions, laboratory results, and medical records as reasonably necessary to:

• Obtain insurance prior authorization for prescribed medications.
• Verify medical and prescription insurance benefits.
• Submit prior authorization requests, appeals, exceptions, and reconsiderations.
• Coordinate benefits with my medical insurance, prescription insurance, and pharmacy benefit manager (PBM).
• Submit clinical documentation requested by insurers or pharmacy benefit managers.
• Coordinate care with specialty pharmacies.
• Complete and submit manufacturer enrollment forms, patient support program applications, bridge medication applications, copay assistance applications, and assistance program applications.
• Coordinate medication dispensing and delivery.
• Receive updates regarding insurance approval, enrollment status, and medication fulfillment.

I authorize CutisCo Dermatology to reproduce, copy, electronically apply, or otherwise use my signature from this authorization on prior authorization requests, insurance appeals, specialty pharmacy enrollment forms, manufacturer enrollment forms, copay assistance applications, patient assistance applications, bridge medication applications, and any other documents reasonably necessary to obtain insurance coverage or access to my prescribed medication.

My signature will only be used for purposes directly related to my medical treatment and medication access.

I authorize CutisCo Dermatology to disclose my contact information, insurance information, demographic information, and relevant medical information to medication manufacturers, manufacturer support programs, specialty pharmacies, distributors, and other organizations involved in helping me obtain my prescribed medication.

I authorize these organizations to contact me regarding:

• Insurance verification
• Prior authorization
• Appeals
• Copay assistance
• Financial assistance
• Bridge medication
• Medication shipment
• Refill reminders
• Nurse educator services
• Patient education
• Medication adherence support
• Other services related to my prescribed medication

I understand that participation in manufacturer-sponsored support programs is voluntary.

I authorize CutisCo Dermatology and organizations involved in coordinating my prescribed medication—including specialty pharmacies, pharmacy benefit managers, manufacturers, and manufacturer support programs—to contact me regarding my medication.

I understand that communications may include:

• Telephone calls
• Voice messages
• Text messages (SMS)
• Secure email
• Electronic messaging

 

These communications may relate to:

• Insurance approval
• Medication access
• Prescription processing
• Additional information needed
• Medication shipment
• Refill reminders
• Financial assistance
• Copay assistance
• Patient support services
• Appointment coordination
• Medication education

 

I understand that standard message and data rates may apply.

I may withdraw this communication authorization at any time by notifying CutisCo Dermatology.

If I may qualify for manufacturer copay assistance, bridge medication, patient assistance, or other financial support programs, I authorize CutisCo Dermatology and participating organizations to determine my eligibility and enroll me when appropriate.

I understand that:

• Participation is voluntary.
• Eligibility is determined solely by the sponsoring organization.
• Financial assistance is not guaranteed.
• Additional information may be requested to determine eligibility.

By signing below, I acknowledge that:

 

• I have read and understand this authorization.
• This authorization is voluntary.
• Refusing to sign may delay or prevent insurance approval or access to my prescribed medication.
• I may revoke this authorization at any time by emailing pa@cutisco.com.  Revocation will not affect actions already taken before my revocation request was received.
• This authorization remains valid for one (1) year from the date of my signature unless revoked sooner.
• Information disclosed under this authorization may be redisclosed by organizations that are not healthcare providers or health plans and may no longer be protected by HIPAA. However, many recipients are independently required by law or contract to safeguard my information.
• I have the right to receive a copy of this signed authorization.