Amgen’s Patient Authorization
Amgen’s Privacy Pledge to Patients
Amgen respects patients and customers and takes the protection of their privacy very seriously. Amgen pledges the following:
- Amgen does not and will not sell or rent your information to marketing companies or mailing list brokers.
- Amgen is careful to only collect and/or use personal identifiable information for the purposes stated in this Authorization and as necessary to provide the services and/or programs the patient or customer chooses to enroll into.
- Amgen practices are consistent with federal and state privacy laws, including HIPAA.
- Amgen program enrollment is voluntary and always provides patients with an easy option to cancel participation.
Uses and Disclosure of Personal Information
I authorize Amgen and its contractors and business partners (“Amgen”) to use and/or disclose my
personal information, including my personal health information, only for the following purposes:
- To operate, administer, enroll me in, and/or continue my participation in Amgen’s Otezla
SupportPlus™ program or any other Amgen-affiliated patient support services and activities
related to my condition or treatment (for example, co-pay card programs, reimbursement assistance
programs, drug coverage verification, nurse educator services, adherence program and disease management
- To contact, with my permission, my doctor and the rest of my health care team and share with them my
health information that may be useful for my care;
- To provide me with informational and promotional materials relating to Amgen products
and services, and/or my condition or treatment;
- To improve, develop, and evaluate products, services, materials and programs related to my condition or
In order for Amgen to provide me with the services and/or programs described above, Amgen needs to collect
and use my personal information, including my personal health information. I understand that my
personal health information may include any information, in electronic or physical form, in the possession
of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company, laboratory
and/or their contractor (“Health Care Provider”). This may include select information from or
about my medical history and general health, my health care plan benefits, payment limits or restrictions
covered by my health care plan policy, and/or my adherence to my treatment.
I authorize my Health Care Providers to disclose my personal health information to Amgen, and between
themselves, as necessary, but only for the purposes stated above in this Authorization. I understand that
certain of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration
from Amgen in exchange for disclosing my personal health information and/or for using my information to
contact me with communications about Amgen products which have been prescribed to me (for example medication
reminder programs) and other patient support services.
Expiration, Right to Obtain a Copy and Right to Cancel
I understand that by signing this form, I authorize my Health Care Providers or others who might hold my
health information to only release it to Amgen employees, as well as to its contractors and business
partners, who are performing the services set forth in this Authorization. I also understand I am
authorizing my personal information, including my personal health information, to be used for the purposes
described above. I understand and agree that by signing below, I am authorizing those who rely on this
Authorization to release my personal health information for the earlier of five (5) years or until my
participation in the program ends through my cancellation, unless a shorter time period is required by state
I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by
calling Amgen at 1-844-468-3952 or by writing to PO BOX 13185, La Jolla, California, 92039. If I cancel my
consent, I will no longer qualify for the services described. I also understand that if a Health Care
Provider is disclosing my personal health information to Amgen on an authorized on-going basis, my
cancellation with Amgen will be effective with respect to any such Health Care Providers as soon as they
receive notice of my cancellation.
No Effect on Treatment
I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or
programs described above is entirely voluntary. I understand that Amgen, as well as Health Care
Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment
or other care, to sign this Authorization. Federal Law (including HIPAA) requires a signed
authorization in order for Amgen to collect this information from my Health Care Providers. I understand I
cannot participate in the listed services and/or programs without signing this Authorization or an
equivalent authorization with my Health Care Providers.
Information Received from Health Care Providers
I understand that once my personal health information has been disclosed to Amgen, federal privacy laws may
no longer apply and protect it from further disclosure. Amgen agrees, however, to protect my personal
health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or
required by law.
Authorization to Contact
I understand and consent to Amgen contacting me using the contact information provided in this form to enroll
me in, operate, and administer Amgen patient support services and/or programs as described above other than
promotional communications by telephone or SMS/text (which I can separately opt-in below). I
understand that the operation and administration of certain of these services and/or programs may require
that Amgen contact me by telephone or SMS/text.