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Copay Savings Program Consent

In connection with enrollee’s registration for the Pfizer Dermatology Copay Savings Card Program (the “Program”), Pfizer and its respective partners, affiliates, subcontractors, and agents (“Pfizer”) may collect and use certain of enrollee’s health and personal information, which may include contact information, demographic information, financial information, and information related to enrollee’s medical condition, treatments, and health insurance and benefits. I authorize and consent to Pfizer receiving, using, and sharing enrollee’s personal information to provide enrollee with access to the Program, products, and other services, which may include the following:

Working with enrollee’s applicable health insurance plan to understand or verify coverage for the Program

Applying to the Program

Determining enrollee’s eligibility for and facilitating enrollment into financial assistance services if eligible, including co-pay assistance

Coordinating enrollee’s prescription through a pharmacy and/or healthcare provider's office, including contacting me to discuss coverage, costs, and eligibility for assistance and other Program administration purposes

Facilitating enrollee’s access to Pfizer products, services, and the Program

Ensuring quality and safety and improving Pfizer’s products and services

Contacting me by mail, e-mail, telephone calls and text messages at the number(s) and address(es) provided for non-marketing purposes

I understand that Pfizer may also share enrollee’s personal information for the purposes described in this consent with enrollee’s healthcare providers, service providers, and any individual I may designate as an alternate contact. I understand that my pharmacy may receive payment or other remuneration for disclosing enrollee’s personal information to Pfizer pursuant to this consent. I can choose not to sign this consent, but Pfizer will not be able to provide the services to enrollee without it. However, enrollee’s healthcare providers may not condition treatment, enrollment, or eligibility for benefits on signing this consent. I also understand and agree that:

This consent is valid until I revoke it.

Personal information released under this consent may no longer be protected by state and federal law, including the Health Insurance Portability and Accountability Act (HIPAA). However, Pfizer will only use and share personal information for the purposes stated on this consent or as otherwise permitted by law.

I have the right to revoke (that is cancel or opt out of) this consent at any time by contacting Pfizer Dermatology Patient Access at 833-956-3376 or 2730 South Edmonds Lane, Suite 300, Lewisville, TX 75067. If I revoke this consent, enrollee will no longer be eligible for the Program. If a healthcare provider is disclosing personal information to Pfizer on an authorized, ongoing basis, my revocation will be effective with respect to such healthcare provider when they receive notice of my revocation. My revocation will not impact uses and disclosures of personal information that have already occurred in reliance on this consent. I understand that this consent will be effective until I exercise my right to revoke.

More information on privacy rights, including specific rights enrollee may have as a resident of certain states, like California, can be found in Pfizer’s privacy policy www.pfizer.com/privacy.

I have a right to receive a copy of this consent.