Patient Privacy & Authorization
By signing and submitting ARJ Infusion Services’ Patient Self-Enrollment and Authorization Form the patient understands and authorizes the following:
I understand I agree to the collection, disclosure and use of my personal health information, including but not limited to, name, address, social security number, telephone number, insurance information, medical condition and treatment (including prescriptions), medical records and other information contained on this form or provided by authorized persons (“Personal Health Information”). I hereby authorize each of my doctor(s) and their staff, health plans, insurers, hospitals, clinics, pharmacies, distributors or other health care providers and those working on their behalf to disclose my Personal Health Information to ARJ Infusion Services, Inc., its employees, affiliates and their representatives. I understand that my Personal Health Information will be used for the following purposes: (i) verifying, investigating, coordinating and resolving insurance coverage or reimbursement inquiries and payment for ARJ Infusion Services; (ii) enrolling me in and contacting me with educational materials and patient management program information and other services related to my therapy or my medical condition; (iii) contacting and providing my Personal Health Information to my insurer, patient advocacy organizations, patient assistance programs, co-pay assistance or similar programs to determine eligibility for coverage and enrolling me in such programs; (iv) managing the Program; and (v) conducting market research or other commercial activity, or aggregating my Personal Health Information with other data for such analysis. I understand that ARJ Infusion Services, Inc., may report back to my healthcare professional(s) any Personal Health Information about me that they may create or receive. I agree that ARJ Infusion Services may contact me in the future via email, mail, and by text message or live, autodialed and/or prerecorded messages at the telephone numbers provided by me. I understand that once my health information is disclosed it may no longer be protected by federal or state law regarding patient privacy and it may be subject to re-disclosure without my permission. I understand that I may refuse to sign this authorization or revoke it at any time in the future, and my refusal or future revocation will not affect my treatment, payment or eligibility for benefits. This authorization will remain valid for ten (10) years after the date of my signature, unless I cancel it earlier by mailing a letter requesting such cancellation to ARJ Infusion Services, Inc., 7930 Marshall Drive, Lenexa, Kansas 66214. Revoking this authorization will not impact ARJ Infusion Services ability to use and disclose Personal Health Information it has received prior to the cancellation. I also understand that infusion services may be changed or end at any time without prior notification by ARJ Infusion Services, Inc.
I understand that I am entitled to a copy of this Authorization.