HIPAA Authorization and Release of Liability
I am entering into this Agreement with ILMEDS, a patient-assistance company, so that I can access medically necessary and lawfully prescribed prescription medication at lower cost.
Confirmations and Representations
I confirm and represent the following:
- I am of the age of majority in the jurisdiction in which I ordinarily reside.
- I am not restricted from making my own medical decisions under the laws of that jurisdiction.
- I certify that I am a resident of the United States and not a resident of any other country.
- I am under the care of a duly qualified and licensed physician in the United States ("my U.S. physician").
- My U.S. physician has examined me within the last 12 months, and I continue to receive ongoing care.
- Any prescription medications dispensed under this agreement are chronic medications I have been taking for at least 3 months.
Authorization for ILMEDS to Act on My Behalf
- I appoint ILMEDS and its delegates and contractors (collectively, "ILMEDS") as my paid agents and attorneys-in-fact to obtain prescriptions corresponding to those issued by my U.S. physician; to select physicians, pharmacies, and other professionals as needed to serve me outside the U.S.; and to arrange for pharmacies to dispense the prescribed medication to me (the "Services").
- ILMEDS may perform any act I could perform myself in having my prescription reviewed by a physician, pharmacist, or pharmacy technician, and in having the medication dispensed and delivered.
- ILMEDS may arrange the purchase and delivery of medications prescribed to me on the terms set forth here.
- I authorize my U.S. physician to release to ILMEDS any personal health information relevant to dispensing the prescribed medication on my behalf.
- ILMEDS and its subcontractor pharmacists and pharmacy technicians may contact my U.S. physician about my prescription and may share information with my U.S. physician, ILMEDS-selected physicians and pharmacists, and my employer or benefits plan administrator (and their respective delegates) for the purpose of obtaining the prescribed medicine and proper payment.
- ILMEDS may make payments on my behalf to pharmacies for dispensing the prescribed medication.
- I request and authorize my employer or plan administrator, as my appointed agent, to pay for products and services relating to the prescription medicine I obtain through ILMEDS in such amounts as are found appropriate in accordance with my benefits plan.
Acknowledgement of International Dispensing for Personal Use
- Any ILMEDS-selected physician is being asked only to review my medical history for the purpose of authorizing medication prescribed by my U.S. physician.
- I wish to obtain a prescription from an ILMEDS-selected physician and enlist ILMEDS to facilitate it.
- I am purchasing medication procured and dispensed internationally for personal use and understand that my medication(s) may be subject to inspection by U.S. customs and border protection. Title to the medication passes to me when it ships from the selected pharmacy.
- I appoint ILMEDS as my paid agent for these purposes and understand that my order may not be returned for refund or exchange.
Release of Liability of ILMEDS and the Plan Administrator
- I acknowledge that the plan administrator has made no representations or warranties to me, including regarding the use of the medication(s) delivered or appropriateness for treating any illness or disease.
- I release the plan administrator and its officers, employees, and agents from (i) any causes of action with respect to errors or omissions by the carrier transporting my order; (ii) any causes of action with respect to errors or omissions by ILMEDS in obtaining the prescription; and (iii) any causes of action regarding the use of any medications delivered through this program.
- I release ILMEDS and its officers, directors, agents, delegates, employees, and contractors from any liability, claim, or cause of action with respect to any prescription dispensed and shipped on my behalf.
HIPAA Release of Protected Health Information
ILMEDS may receive, collect, use, and store demographic and personal health information as necessary to verify and process prescription orders. ILMEDS will act as a custodian of my personal information and will take steps to safeguard it from improper disclosure or use.
This document constitutes my authorization and consent for my U.S.-based health plan, physician, healthcare professional, hospital, clinic, laboratory, medical facility, or other healthcare provider to release my protected health information to ILMEDS as needed to facilitate the fulfillment of my prescribed medications.
- This authorization is made voluntarily.
- ILMEDS is authorized to request and receive information from the healthcare sources described above for purposes of providing the Services.
- Such requests may include any medical records and details necessary for ILMEDS to provide the Services (e.g., medical condition, health status, claims experience, medical history, and physical examinations).
- ILMEDS is authorized to use my personal information and disclose it to the physicians and pharmacies it selects, including locations outside the U.S., for the purpose of providing the Services.
- I acknowledge that HIPAA generally allows re-disclosure of protected health information once shared with a third party unless prohibited by agreement. ILMEDS agrees that protected health information it receives will not be re-disclosed except as needed to provide the Services described here.
- I may revoke this authorization at any time by providing written notice to ILMEDS. Revocation will not affect any action taken in reliance on it prior to receipt of the notice.
- This authorization remains in effect from the date of acceptance until six months following the conclusion of Services, or until revoked.
Informed Consent
I represent and warrant that, prior to engaging ILMEDS, I have been advised about the risks, benefits, and alternatives of using the prescribed medication. I give my informed consent to receive the prescribed medication(s) sourced by ILMEDS. I may revoke this informed consent in writing at any time.
Agreement
By submitting an order or using the Services, I agree to the terms of this Patient Consent & HIPAA Authorization.