Access 360 is a resource provided by AstraZeneca to patients and their caregivers. Access 360 can help patients understand their coverage for AstraZeneca products, their financial obligation, as well as help connect patients with resources to cover the cost of their medicines. It can also assist eligible patients with access to AstraZeneca medicines free of charge. By signing this Patient Authorization Form, you are allowing Access 360 to access necessary Protected Health Information (PHI) to provide support that you or your healthcare provider may request.
Information to be disclosed or used
Your doctors and specialty pharmacies ("Healthcare Providers") and healthcare plans or programs ("Insurers"), may share the PHI with Access 360, as well as contractors or affiliates of AstraZeneca. This PHI includes:
The patient's health records relating to his/her prescription
Information about the patient’s healthcare plan benefits
Any information having a bearing on the patient’s health or adherence to medical care
Who may see and use my phi
PHI may be seen by Access 360, as well as employees, contractors, or affiliates of AstraZeneca that perform access support. The patient’s PHI may be used only in the following ways:
Verifying, investigating, and assisting with the coordination of coverage for and access to AstraZeneca medicines and providing updated information of such to providers
When necessary, contacting the patient about AstraZeneca's Patient Access Programs
Tracking the patient's prescription for and shipments of AstraZeneca products if requested by the patient’s physician
Performing internal analyses to improve Access 360 programs to better meet patient needs
I may cancel my authorization at any time by sending written notification of my withdrawal to: Access 360 Program, One MedImmune Way, Gaithersburg, MD 20878, faxing written notification to Access 360 at
1-844-FAX-A360, or by calling Access 360 at 1-844-ASK-A360.
Access 360™ Patient Authorization
By signing below, I agree to the use and disclosure of the PHI and who may see it for the purposes described on the previous page. If I cancel this Authorization, the Healthcare Providers and Insurers are prohibited from further disclosing my PHI to AstraZeneca, including its contractors and affiliates; however, it will not impact AstraZeneca's ability to use and disclose PHI already received prior to the receipt of the revocation. If I refuse to sign this Authorization, or revoke it later, I will not be able to receive assistance from Access 360 Programs. I understand that I am not required to sign this Authorization, and that my therapy, payment for therapy, health insurance enrollment, or eligibility for benefits by the Healthcare Providers and Insurers, as applicable, will not be affected if I refuse to sign this Authorization. I further understand that, once the recipient receives my PHI, it may be redisclosed by the recipient and may no longer be protected by federal privacy laws. If I am the caregiver for the patient, I confirm that I am authorized to sign on behalf of the patient. AstraZeneca agrees to protect my PHI by using and disclosing it only for the purposes specified.
Signature of Patient/Caregiver
By clicking SUBMIT, I affirm that I am authorized to sign this form and that my electronic signature on this form has the same effect as my written signature. In the event I encounter difficulty in obtaining a copy of this form, I understand I may call 1-844-ASK-A360 (275-2360) for assistance.
This authorization expires two (2) years from the date I sign this form unless a shorter period is required by state law.