Medical Information Release Form

By signing this agreement, you acknowledge and accept that NeedyMeds PAP-APP Coordinators, NeedyMeds Helpline Counselors, and other NeedyMeds (collectively referred to as NEEDYMEDS and/or EPLS employees (EPLS) will have access to your protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA).  You give permission for NEEDYMEDS or EPLS representatives to communicate with you via telephone, text message, e-mail, and traditional mail regarding your medications, and to submit forms and communicate with patient assistance programs on your behalf.  This information will be used to help complete application forms on your behalf.

 

 

EPLS and NEEDYMEDS function only to assist in the procurement of legal medications that have been prescribed by a physician. As a condition of EPLS and NEEDYMEDS providing services to assist Plan Participant in this matter, Plan Participant agrees to the following terms:

·         EPLS and NEEDYMEDS (1) is not a legal, tax, or medical advisor, nor a medical provider or pharmacy; (2) cannot and explicitly does not make any medical, financial, tax, or other decisions for Plan Participant in any manner or capacity; and (3) has no part in the manufacture, sale, marketing, prescription, or application of any medical service or supply. Plan Participant may neither hold EPLS,  NEEDYMEDS out as such to any third party, nor attempt to hold EPLS, LLC legally, financially, or otherwise responsible in any such capacity.

·         Any medicine ingested or otherwise administered in any way by Plan Participant is taken at Plan Participant’s sole discretion, and should always be subject to instructions by a physician. Plan Participant may not hold EPLS nor NEEDYMEDS responsible for any effects of any medicine or other item, regardless of whether or not such effects are medicinal in nature and regardless of whether such effects have been advised of or disclosed by a physician.

·         Plan Participant is strongly encouraged to consult an appropriate medical professional in connection with any questions about the administration, effects, or propriety of any medication.

If you would like to authorize additional people (family, friend, or advocate) to have access to your protected health information, complete this section below.

I hereby authorize the disclosure of my protected health information to the following individuals:

E-Mail : rxinfo@epls.biz

Phone: 800-572-6091

Fax: 888-246-6527

50 Whittemore St.

Gloucester, MA 01930