Disclaimer
Certified V-Go Trainers provide training on how to fill and use V-Go. The training provided is not intended to replace any medical advice given from your healthcare provider. Only your healthcare provider is qualified to provide medical advice and all questions relating to your treatment regimen should be directed to the your healthcare provider.
Please use dashes between numbers (xxx-xxx-xxxx)
Authorization for Use and Disclosure of Personal Health Information
By signing below, I authorize my healthcare providers, including any pharmacy that may receive my prescription for V-Go Wearable Insulin Delivery® (“Pharmacy”), to disclose personal health information (“PHI”) about me, including health information relating to my medical condition, prescription, and insurance coverage, to MannKind Corporation, its affiliates, and its agents that have been hired to administer the V-Go Cares® Program on its behalf (collectively, “MannKind”) in order for MannKind to (1) enroll me in V-Go Cares; (2) establish my benefit eligibility and potential out-of-pocket costs for V-Go; (3) communicate with my healthcare providers and health plans about my treatment plan; (4) provide support services including patient education, product training and financial support for V-Go; (5) help get V-Go shipped to me or my healthcare providers; and (6) facilitate my participation in V-Go patient programs that I have elected to receive information about. I authorize MannKind to use my PHI for the purposes listed above, as well as to contact me for reasons related to the V-Go Cares patient support services, to obtain further information or clarification regarding any adverse event I may experience, and to solicit my opinions regarding V-Go and MannKind’s products and services. I authorize MannKind to disclose that I am on V-Go in voice-mail messages left for me related to the V-Go Cares Program. I understand that the training or education provided by V-Go Cares is not meant to provide or replace any medical advice from my healthcare providers and questions related to my treatment regimen should be directed to my healthcare provider. I understand that once my PHI has been disclosed to MannKind, it may no longer protected by federal privacy law and could be re-disclosed to others, but that MannKind intends to use and disclose my PHI received pursuant to this authorization only for the purposes described above or as required by law. I understand the Pharmacy may receive financial remuneration from MannKind for disclosing PHI to MannKind and for providing support services to me, including sending communications to me, for purposes of the V-Go Cares Program as outlined in this authorization.
I would also like to receive patient support information from V-Go Cares via mail or email, which may include disease state educational material, information about V-Go and information about MannKind. I understand that I can withdraw this authorization by calling V-Go Cares at 1-866-881-1209 or mailing a letter with my notice of revocation to V-Go Cares, 600 Emerson Road, Suite 300, Creve Coeur, MO 63141. I understand that if I do revoke the authorization, it will thereafter be invalid, but that uses, and disclosures made in reliance on the authorization prior to its revocation will not be invalidated. I understand that I may refuse to sign this form and, if I do so, I will not be able to participate in V-Go Cares, but such refusal will not affect my eligibility to obtain medical treatment or eligibility for insurance coverage. This authorization expires five years after the date I sign it below. I understand that I am entitled to receive a copy of this authorization.
Consent to Receive Text and Mobile Messages
I agree to be contacted by text messages (“texts”), placed by MannKind Corporation or its agents or service providers (collectively, “MannKind”) to the mobile phone number I have provided, for the purpose of helping me stay on therapy, which may promote or advertise the MannKind’s products included in the therapy plan. I certify that the number I am providing belongs to me or a family member and not a third party. I understand that I may opt out of receiving such messages at any time by calling 1-866-881-1209 or replying “STOP” by text to any text from MannKind, and that my consent to being contacted by text messages is not a condition for me to participate in the V-Go Cares® Program or to purchase any products or services.
US-VGO-0104
