Rx Initiatives LLC Discount Program Release of Information

First Name  
Last Name  
Birth Date (Format MM-DD-YYYY)  
Phone Number (Format XXX-XXX-XXXX)  

By submitting this form, I agree that I understand the information below and authorize Fairview Pharmacy Services LLC to release my protected health information as indicated.

Rx Initiatives LLC Discount Program Release of Information

This form is requires your consent in order for you to participate in a discount program made available to you through Fairview Pharmacy Services, LLC.

Rx Initiatives

Rx Initiatives LLC negotiates discount contracts with pharmaceutical and/or device manufacturers for products used for treatment of fertility disorders. In exchange for discounts, available to you by signing up for the service, the above companies provide market information to the manufacturers. Rx Initiatives LLC does not share your protected health information with the manufacturers.

Release of Information

These discount programs are not a healthcare benefit. If you chose to enroll in a discount program, we need your approval to send information about your prescription to Rx Initiatives, LLC and/ or their claims processor.
By submitting this form, you acknowledge that the discount drug you receive is not being covered as part of your health benefit plan.

For more information about information privacy practices

This release is intended to protect the privacy of your health information, yet allow the appropriate flow of information necessary to care for you. Fairview takes privacy regulations seriously and we will do our best to protect your privacy while providing you with the highest quality health care services available.
Discrimination is Against the Law. We comply with applicable Federal civil rights laws. We do not discriminate against, exclude or treat people differently because of race, color, national origin, age, disability or sex.
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