AstraZeneca Access 360™ Patient Authorization Form (PAF)

Access 360 is a program that provides patients and their providers with access and reimbursement support for AstraZeneca products.

The purpose of this website is to allow patients and their caregivers to electronically sign the Access 360 Patient Authorization Form (PAF), providing consent to allow Access 360 as well as employees, contractors, or affiliates of AstraZeneca that perform access support to have Protected Health Information (PHI). This authorization is required in order for Access 360 to provide access and reimbursement resources for patient-specific support.

If you have any questions regarding the Access 360 program or the Access 360 Patient Authorization Form, please contact us at 1-844-ASK-A360 (275-2360).

Patient Information

Patient/Caregiver Information

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Prescriber Information

Important Information

Access 360

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

cancelling authorization

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.

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Today's Date

Monday 10/23/2017

This authorization expires two (2) years from the date I sign this form unless a shorter period is required by state law.

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