HIPAA Authorization to Use Your Protected Health Information for Sponsored Medication Adherence and Marketing Programs
Last Updated September 29, 2020
I understand my pharmacy uses mscripts’ Mobile Pharmacy Service to enhance my experience and maximize efficient pharmacy-patient communications. I hereby authorize my pharmacy and mscripts to use my information, including but not limited to, my name, age, other demographic information, phone number, e-mail address, other contact information, and all prescription-related data on file with my pharmacy, to:
Send me health-related messages regarding treatment options or other health-related products or services for which my pharmacy or mscripts may be paid to make by outside third parties, including but not limited to, invitations to participate in adherence programs, educational information about my prescriptions and other products I may be interested in; coupons; advertisements, etc., and for my pharmacy and mscripts to evaluate the effectiveness of such communications; and
Provide my information to a third party manufacturer or health plan for such third party to communicate with me about its product or services.
I understand and agree that these communications may be made within the mobile application, by text message, and by email.
I understand that signing this Authorization is voluntary. I understand that my receipt of treatment or eligibility for health benefits will not be conditioned on whether I sign this Authorization, and I will still be able to use the mscripts Mobile Pharmacy Service as a registered user if I do not sign this Authorization. I also understand that if I choose not to sign this Authorization, my choice will not impact or otherwise limit my pharmacy’s or mscripts’ use or disclosure of my information for purposes and activities that do not require my Authorization under applicable law, which includes certain adherence and other health-related communications including refill and pickup reminders and weekly pharmacy offerings. I understand that any of my information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by HIPAA.
This Authorization is valid until revoked or three (3) years from the date signed, whichever occurs first. I may revoke this Authorization at any time by:
Emailing University Pharmacy (and including my name, mobile phone number, and pharmacy name in the email);
Calling (888) 507-6735 choose Option 3 for Support; or
Mailing a written request to: End User Support, mscripts, 445 Bush Street, Suite 200, San Francisco, CA 94108 (and including my name, mobile phone number, and pharmacy name in the written request).
If I choose to revoke this Authorization it will not be effective to the extent that my pharmacy or mscripts has already used or disclosed my information in reliance on this Authorization.
I can obtain a copy of this HIPAA Authorization on my “Account” page in my Mobile Pharmacy Service mobile application.