By signing this Authorization to Release Health Information, I authorize my health care providers, pharmacies, health plans, and insurers (and contracted services) to disclose to Molecular Biologicals and its third-party business partners information about my insurance coverage, diagnosis, disease, treatment, and payment for my treatment for the purpose of obtaining patient support services including investigation of my health insurance coverage, communicating with me about my experience, providing support services, and operating and administering the program. I understand that once my
information has been released to Molecular Biologicals and its affiliates, federal privacy laws may no longer protect the information from further disclosure, but that Molecular Biologicals and affiliates intend to use this information for purposes of this authorization or otherwise allowed by law. I understand I may refuse to sign this authorization and it will not impact my ability to obtain medical care, insurance coverage, or access to health benefits including access to treatment. However, by not signing, Molecular Biologicals
can not provide these support services. This authorization will expire after two years from the date I signed. I may decide to withdraw this authorization at any time by sending a written notice that includes my name, address, and phone number to RxTalents, LLC ATTN: Patient Services, 4900 Carlisle Pike, Mechanicsburg, PA 17050

By signing below, I certify that I have read and understood the Authorization to Release Personal Health Information and agree to its terms. I understand that I may request a copy of this Authorization.