Enroll in Pfizer Migraine Patient Access

Consent to Collect and Use 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 and use such information, which is considered sensitive information in some states, in connection with operation of the Program.

Health Information Collected. 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.

Duration. By signing the consent to use, I agree that these entities may use my Health Information to administer the Program or as permitted or required by applicable privacy laws. I permit such use for one year after the dates I sign the consent, 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 consent. I understand that if I revoke my consent, it will not have any effect on any collection or uses 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 my consent to collect and use my Health Information is 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.