Informed Consent and HIPAA Acknowledgement

Patient Information
Name*

Patient First NamePatient Last Name
Sex*
Date of Birth*

MonthDayYear
Date
Nationality
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Number
Please enter a valid phone number.

Prescriber Information
Prescriber Name (the provider who wrote the prescription for the medication(s) you are getting from NASH)

Prescriber First NamePrescriber Last Name
Practice Name
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Specialty Drug(s) to be filled by NASH

HIPAA Acknowledgement & Release Signature
By my signature below, I release that I understand:
- A copy of my medical records will be requested from my current healthcare provider and stored by the Network of Advanced Specialty Healthcare (“NASH”) in a confidential manner in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
- NASH may share my medical records with one or more prescribing provider(s) pursuant to HIPAA and the Medical Records Release Form.
- I have voluntarily chosen to enter the NASH Specialty Pharmacy Program.
- I have voluntarily chosen to receive the medication for my own personal use as a continuation of therapy.
- I am of legal age and authorized to execute this consent form.
- I will immediately notify my U.S. prescribing provider and/or my primary care provider of any medical conditions or significant physical or lifestyle changes which may adversely affect my personal health or the effectiveness of the medication.
- I have received education about potential side effects of the medication, when they may occur, and when and where I should seek treatment. I understand that if I experience any side effects, I am responsible for following up with my primary care provider at my expense.
- I have had the opportunity to ask questions about the medication, and all my questions have been answered. I understand the benefits and risks of the medication.
I acknowledge I have received a copy of the Notice of Privacy Practices which is viewable here.

Please remember to sign, date and submit this form!
Patient or Guardian Name

First NameLast Name
Patient or Guardian Signature

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