Patient Consent Form Test Page

Customer Experience Center Authorization Form

  • MannKind Corporation is committed to ensuring every patient has the best possible experience with Afrezza® (insulin human) Inhalation Powder. In support of this goal, MannKind has established a comprehensive Customer Experience Center program to provide support and assistance to patients and their caregivers. The team at MannKind is committed to answering your non-clinical questions, helping to support and guide you through the insurance process, and providing education and training on the use of Afrezza.

    When communicating with you, we will receive certain personal health information from you. We recognize that your health information is sensitive and it is important that you understand what information we collect and how we use the information we receive.

    Why is it necessary to provide this authorization?

    In order for MannKind to provide you with patient support through the MannKind Customer Experience Center program, we will need to receive, look at, use, and disclose some of your personally identifiable information (“PII”), including certain health information of yours. By signing this form, you are directing and authorizing your healthcare provider and healthcare plan to transmit your PII to us and you are authorizing us to receive, use and further disclose it as necessary to assist you and communicate with you. You can choose not to sign this form and you may still receive Afrezza as prescribed by your healthcare provider, however, please understand that we cannot assist you and provide services without this authorization.

    What information will be shared with MannKind?

    • Name and contact information provided
    • Health information related to my treatment with Afrezza, including, but not limited to, medical history, relevant diagnoses, certain lab results, prescription information, and other health information
    • Information about my healthcare plan benefits, including my deductibles and anticipated annual and lifetime out-of-pocket costs
    • Any other information that you may voluntarily choose to provide

    How will my information be used by MannKind?

    • To enroll, and/or continue your participation in and to operate and administer MannKind’s patient support programs or any other MannKind-affiliated activities related to my condition or treatment (examples include, but are not limited to, co-pay card programs, insurance benefit verification and support, nurse educator services, adherence programs and disease management support)
    • To contact me by mail, email, SMS/text message, facsimile, telephone, and other means to enroll me in and administer patient support programs and services and to provide me with free educational information and materials
    • To communicate with my doctor and the rest of my healthcare team and receive from and share with them my health information that may be useful for my care and to facilitate requested patient support services
    • To improve, develop, and evaluate products, services, materials and programs related to my condition or treatment

    MannKind’s Commitment to You

    • We do not and will not sell or rent your information to marketing companies or mailing list brokers
    • We will only collect and use PII for the purposes stated in this Authorization and as necessary to provide the services and/or programs each patient or customer chooses to enroll into
    • Your enrollment and authorization is completely voluntary and can be cancelled at any time
    • We take seriously our obligation to comply with state and federal laws that protect your personally identifiable information, including your health information

    I certify that I am at least eighteen (18) years of age. I understand that I may cancel this authorization and choose not to receive support services or information from MannKind by notifying a program representative by telephone at 1-818-661-5047, or by sending a letter to 30930 Russell Ranch Road, Suite 301 Westlake Village CA, 91362. I understand my cancellation will not apply to any information already used or disclosed base on this authorization.

    Authorization for Transmission of Personal and Protected Health Information

    Notification of use and signature

    In order for MannKind to provide me with patient support services and/or programs, MannKind needs to collect and use my personal information, including my protected health information. I understand that my protected health information may include any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company, laboratory and/or their contractor (“Health Care Provider”). This may include select information from or about my medical history and general health, my health care plan benefits, payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment.

    I authorize my Health Care Providers to disclose my protected health information to MannKind, and between themselves, as necessary, but only for the purposes stated above in this Authorization.

    Expiration, Right to Obtain a Copy and Right to Cancel

    I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to only release it to MannKind Customer Experience Center agents, as well as to its contractors and business partners performing the services set forth in this Authorization. I also understand I am authorizing my personal information, including my protected health information, to be used for the purposes described above.

    I understand and agree that by signing below, I am authorizing those who rely on this Authorization to release my protected health information for the earlier of five (5) years or until my participation in the program ends through my cancellation, unless a shorter time period is required by state law.

    I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling MannKind at 1-818-661-5047 or by writing to 30930 Russell Ranch Road, Suite 301 Westlake Village CA, 91362. If I cancel my consent, I will no longer qualify for the services described. I also understand that if a Health Care Provider is disclosing my protected health information to MannKind on an authorized on-going basis, my cancellation with MannKind will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation.

    No Effect on Treatment

    I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely voluntary. I understand that MannKind, as well as Health Care Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment or other care, to sign this Authorization. Federal Law (including HIPAA) requires a signed authorization in order for MannKind to collect this information from my Health Care Providers. I understand I cannot participate in the listed services and/or programs without signing this Authorization or an equivalent authorization with my Health Care Providers.

    Information Received from Health Care Providers

    I understand that once my protected health information has been disclosed to MannKind Federal privacy laws may no longer apply and protect it from further disclosure. MannKind agrees, however, to protect my protected health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or required by law.

    Authorization to Contact

    I understand and consent to MannKind contacting me using the contact information provided in this form to enroll me in, operate, and administer the MannKind Customer Experience Center Program as described above. I understand that the operation and administration of these services and/or programs may require that MannKind contact me by telephone or SMS/text and that my cell phone carrier’s standard rates may apply for calls or text messages to my cell phone.

    Patient Information / Preferred Method of Contact
  • This Authorization and related documents may be signed electronically. If signing electronically, by typing your name in the signature section of this page, you agree that you are signing this document. You understand that your electronic signature is legally binding, just as if you signed a paper document, and you acknowledge that you have read and understand this Patient Authorization Form. By signing below, I am providing my consent and indicating my legal authorization for MannKind and its contractors and business partners to use and share the personal information I give only for the purposes described within this Authorization.

WARNING:


If you are reporting an Adverse Event and/or device complaint, please contact MannKind Medical Information at 1-877-323-8505 or MannKind@druginfo.com. Do not use this form for adverse events and/or device complaints.