Enroll in the Pfizer Migraine Patient Access Program

Consent to Collect, Use and Disclose Personal Health Information

Pfizer Inc. (“Pfizer”) collects certain personal health information (described below) about individuals so that it may operate the Pfizer Migraine Patient Access Coordinator Program (the “Program”). Pfizer is seeking this consent because it needs to collect, use and disclose such information, which is considered sensitive information in some states, in connection with operation of the Program.

Health Information Collected and/or Shared. The personal health information Pfizer and its service providers collect includes name, patient identifier, healthcare provider information, and/or data that identifies your health condition, diagnosis, and/or treatment (collectively “Health Information”).

Purposes of Collection and Use. Your Health Information will be used for the following purposes:

• To administer the Pfizer Migraine Patient Access Coordinator Program.
• To provide you and, as appropriate, your health care provider details related to obtaining access to the prescribed migraine medication including but not limited to insurance coverage criteria, out of pocket cost estimates, copay savings program details for eligible patients, prior authorization requirements and insurance plan requirements and limitations.

Purposes of Sharing. Your Health Information will be shared for the following purposes:

• To administer the Pfizer Migraine Patient Access Coordinator Program.

Duration. By signing the consent to use and/or the consent to disclose, I agree that these entities may use and/or disclose my Health Information to administer the Program or as permitted or required by applicable privacy laws. I permit such use and/or disclosures for one year after the dates I sign each consent respectively, unless and until I revoke (i.e., take back) it in writing prior to that time.

Revocation. I may revoke my consent at any time, except to the extent that Pfizer has taken any action in reliance on my consents. I understand that if I revoke my consent, it will not have any effect on any collection, uses, or disclosures of my Health Information that occurred prior to receiving my revocation. To revoke, I understand that I must notify Pfizer in writing at the following email: [email protected].

I understand that both my consent to collect and use and my consent to disclose my Health Information are voluntary and may be revoked in writing at any time. I further understand that not permitting the processing of my Health Information may result in my health plan or insurer not being able to participate in the Program.
I have read this consent and/or had its contents read to me. I fully understand the terms and conditions described above.