Informed Consent and HIPAA Acknowledgement

Patient Information
Name*

First NameLast Name
Gender*
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.

Prescribing Physician Information
Physician Name (The physician who wrote the prescription for the medication(s) you are getting from NASH)

First NameLast Name
Practice Name
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of NASH Prescribed Medication(s)

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 physician(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.
- I am of legal age and authorized to execute this consent form
- I will immediately notify my U.S. prescribing physician 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.
By my signature below, I acknowledge I have received a copy of the Network of Advanced Specialty Healthcare's Notice of HIPAA Privacy Practices. You can view our notice 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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