PTC Cares 2021 Insurance Renewal Form

*Required
PATIENT INFORMATION
Patient First Name*
Please enter the patient‘s first name.
Patient Last Name*
Please enter the patient‘s last name.
Date of Birth*
Please enter the patient‘s date of birth.
Gender*
Male
Female
Please make a selection.
Guardian/Caregiver's Name*
Please enter the guardian/caregiver‘s name.
Relationship*
Please enter the guardian/caregiver‘s relationship to the patient.
Address*
Please enter your address.
Apt
City*
Please enter your city.
State*
Please make a selection.
Zip*
Please enter your ZIP code.
Email Address*
Please enter your email address.
Home Phone*
Please enter your home phone number.
Mobile
Please enter your mobile number.
Would you like to receive text messages from the specialty pharmacy?
Yes
No
Preferred Contact Number*
Home
Mobile
Please make a selection.
Best Time to Reach Me*
Please make a selection.
OK to Leave Message*
Yes
No
Please make a selection.
Language Preference
INSURANCE INFORMATION
Primary Insurance
Drug Insurance*
Please enter the insurance company‘s name.
Phone Number
Please enter the insurance company‘s phone number.
Policy Number*
Please enter the policy number.
Group Number
Please enter the group number.
Policyholder Name*
Please enter the policyholder‘s name.
Rx Member ID
Please enter the Rx Member ID.
Rx BIN (if applicable)
Rx Group ID*
Please enter the Rx Group ID.
Secondary Insurance
Drug Insurance
Please enter the insurance company‘s name.
Phone Number
Please enter the insurance company‘s phone number.
Policy Number
Please enter the policy number.
Group Number
Please enter the group number.
Policyholder Name
Please enter the policyholder‘s name.
Rx Member ID
Please enter the Rx Member ID.
Rx BIN (if applicable)
Rx Group ID
Please enter the Rx Group ID.
Patient Authorization for 1) Disclosure of Information 2) Program Participation 3) Marketing Materials
I have read and agree to the following HIPAA Authorization to share health information and participate in the PTC Cares™ program. I authorize my healthcare providers and health plans to disclose personal and medical information related to my use or potential use of EMFLAZA® (deflazacort) to PTC Therapeutics, Inc. and its agents and contractors including, but not limited to, PTC’s specialty pharmacy partners and authorize PTC Therapeutics, its agents, and my pharmacies to use such information to: 1) determine benefit eligibility; 2) communicate with my healthcare providers and health plans about benefit, coverage and medical care; 3) provide me with support services for EMFLAZA® (deflazacort); 4) contact me and leave messages about EMFLAZA® (deflazacort); 5) provide me with information or materials related to EMFLAZA® (deflazacort) or my relevant medical conditions; 6) contact me about the PTC Cares™ program, which may include patient services such as education, training, nurse and pharmacy support; and 7) I understand that my pharmacy may receive remuneration in exchange for sharing and using my information pursuant to this authorization. PTC Therapeutics will maintain the confidentiality of my personal and medical information in accordance with its privacy policy and will use this information only for the purposes described above or as permitted by law. However, I understand that personal and medical information disclosed to PTC Therapeutics pursuant to this authorization may be subject to re-disclosure, and privacy laws may no longer restrict its use or disclosure. I further understand that I may refuse to sign this authorization and that my refusal to sign this authorization will have no impact on my eligibility to receive health plan benefits or treatments from my healthcare providers, but I will not have access to support services from the PTC Cares™ program. I understand that I have the right to revoke this authorization at any time in the future, except to the extent that actions have been taken in reliance on the authorization, by submitting a written notice to PTC Therapeutics via fax to 1-908-222-7231 or by mail to PTC Therapeutics, Inc., Attention: Compliance Officer, 100 Corporate Court, South Plainfield, NJ, 07080-2449. I understand that after I have revoked my authorization, PTC Therapeutics will stop using the personal and medical information already obtained for the purposes described above. I am entitled to a copy of this authorization, which expires 10 years from the date it is signed by me (unless earlier termination is required by applicable state law). The personal, insurance and health information I have provided on this form is complete and accurate to the best of my knowledge. I will update my information promptly if any of the information reflected on this form changes by contacting PTC Cares™ at 1-844-478-2227.
US-CORP-0226
SPANISH VERSION OF THE FORM
Questions?
Simply call your PTC Cares Case Manager
1-844-4PTC-CARES (1-844-478-2227)