By my signature below, I consent to the administration of the prescribed medication by the Prescriber of Administered Medication, where permitted by law, and to be contacted at the phone number provided above regarding this pharmacy facilitation service. I also release the Network of Advanced Specialty Healthcare (“NASH”) and its agents from all liability, including acts of omission or commission, resulting or arising from my receipt of this medication. I understand that:

• 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 US prescribing physician and/or my primary care physician of any medical conditions which may adversely effect my personal health or the effectiveness of the medication.
• I have received education about potential side effects of the medications, 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 understand that a copy of my medical records will be requested and stored in a confidential manner in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

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!