IUD/LARC Order Form

I authorize the use and/or disclosure of my private health information, described below, which may include "Protected Health Information" or "PHI" as defined by the Health Insurance Portability and Accountability Act of 1996 (as amended, "HIPAA"). In general terms, I understand that Protected Health Information is health information that identifies the referred patient or that could reasonably be used to identify the referred patient. I understand that this authorization is voluntary. I authorize my healthcare providers, including my physicians, pharmacies, and my health plan insurers to share my name, address, and phone number along with my prescription, medical diagnosis, treatment, and insurance information with My-IUD.com, LLC and its agents and contractors. These agents include a company that provides reports to My-IUD.com, LLC on sales and a company that provides quality control and checks the accuracy of reports on sales. I understand that certain healthcare providers, such as my pharmacies, may receive payment from My-IUD.com, LLC in connection with the disclosure of my PHI as described in this authorization.

I understand that My-IUD, LLC d.b.a. MyIUDSupply.com and its agents will supply the IUD ordered by my primary provider (referring Physician). I understand that through the terms of usage authorized by my primary provider that My-IUD, LLC will bill my insurance carrier for the IUD supplied for insertion. I also understand that the IUD supplied may be considered a medical referral through a collaborative practice agreement between my primary provider and My-IUD, LLC and that my encounter with my primary provider through agreement also extends to My-IUD, LLC and its agents.

I allow the use of my PHI and the sharing of my PHI to:

1. Communicate with the referred patient, my healthcare providers, and health plans about my medical care, including treatment with Mirena, Liletta, Kyleena or Paragard;
2. Provide information on coverage and reimbursement of Mirena, Liletta, Kyleena or Paragard to the referred patient and my healthcare providers;
3. Facilitate returns of Mirena, Liletta, Kyleena or Paragard;
4. Be used for sales purposes, including to evaluate healthcare provider prescribing patterns;
5. Comply with applicable law. I understand that any personal information provided on this form will not be used for any purposes other than those described above unless I give written consent, or it is required or permitted under the law, and my name and all other identifying information is removed.
6. I understand that MyIUDSupply may contact me by telephone or telemedicine for the following reasons: verification and coordination of benefits, confirmation of IUD ordered and consent, review of clinical information including safety and educational instructions.

This authorization will remain in effect for 1 year after the date I sign it and will expire after 1 year unless I revoke it prior to this time. I can withdraw (i.e., take back) this authorization earlier by sending a written request to My-IUD.com, LLC, 2635 South Cobb Drive, Smyrna, Georgia 30080, except to the extent my healthcare provider or health plan has taken action in reliance on my authorization. I understand that if I revoke this authorization, it will not have any effect on any actions my healthcare providers or my health plan may have taken before receiving the revocation, and will not affect My-IUD.com, LLC ability to use and disclose any information it has already received. I also understand that persons or entities that receive my PHI under this authorization may not be required by privacy laws (such as the HIPAA Privacy Rule) to protect the information and may share it with others without my permission, if permitted by laws applicable to them. I may refuse to sign this form, and refusal will not affect my treatment, payment for treatment, enrollment in a health plan, or eligibility for benefits.

Authorized Purposes

I understand that the MyIUDSupply.com will receive my health and personal information, which may include my name, address, patient insurance identification number, date of birth and other information necessary to obtain health insurance benefit verification for the following purposes: (1) the administration of MyIUDSupply.com IUD Process; (2) to conduct benefit verification determining insurance reimbursement and coverage of for your selected IUD; (3) to contact me to discuss any relevant co-pay; (4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare provider; (7) to contact me by telephone in furtherance of conducting benefits verifications investigations and/or specialty pharmacy dispensing.

I have read this entire authorization and/or had its contents read to the referred patient. I have had an opportunity to ask questions about the uses and disclosures of PHI described above, and all of my questions have been answered to my satisfaction. I authorize the use and disclosure of my information as described in this form. I understand that I am entitled to receive a signed copy of this authorization.

Please see Important Safety Information for Mirena, Liletta, Kyleena and Paragard and accompanying full Prescribing Information on our website, the Bayer or Allergan website, or in the package insert included with the IUD.