Accuracy of Information
I certify that the information provided here and any subsequent information I provide is complete, truthful and accurate to the best of my knowledge, and that I am unable to afford the medication requested. I understand that additional information may be requested to process this application, but that all medical and financial information will be kept confidential as required by law. I understand that the Product(s) made available to me under this program may be denied to me if I do not fully cooperate with efforts made to verify the information provided in this application, or if I do not take steps to secure alternative means of prescription coverage that are available to me, after I become aware of such alternatives. I certify that I shall not seek reimbursement for any medication dispensed as part of this program. ReUnite RX, LLC (“ReUnite”) is not obligated to verify any of the information submitted or to confirm other medications that I am taking.
Authorization and Privacy
I hereby authorize my health plans, physicians, and pharmacy providers to disclose to ReUnite and its affiliates, agents, representatives and service providers (" Recipients"), and authorize the Recipients to access, obtain, use, disclose or receive, my individually identifiable health information, which may include information related to my medical condition, treatment, care management, health insurance, and prescriptions. I understand that this authorization is voluntary, but that if I do not sign it, I may not be able to receive services from ReUnite. I understand that information released under this authorization may no longer be protected by state and federal law. Recipients may use, and disclose to appropriate organizations, my information as necessary to process this application, assist in the identification of other patient assistance resources, verify the information provided in this application, and report information to ReUnite and its affiliates, agents, representatives, and service providers. I understand that I may withdraw my authorization in writing by contacting ReUnite at any time, except to the extent that action has already been taken in reliance on this authorization. I understand that if I do not withdraw my authorization, this authorization will be in effect for one year from the date of enrollment if approved for the program. I understand that my pharmacy may receive compensation in exchange for reports containing my information.
I authorize ReUnite Rx to send me correspondence via email or text messaging.
Program Terms, Conditions, and Eligibility Criteria
1) This offer is valid only for eligible patients and is good for use only when presented with a valid prescription for Follistim AQ Cartridge (follitropin beta injection), Ganirelix Acetate Injection, and/or Pregnyl (chorionic gonadotropin for injection, USP) at the time the prescription is filled by the pharmacist and dispensed to the patient. 2) This offer is only valid at participating ReUnite Rx network pharmacies. Visit www.reuniterx.com to see a list of our participating pharmacies. 3) This program is valid only for cash paying patients. This offer is not valid for use by patients eligible or enrolled in Medicare, Medicaid, or other federal or state programs, or private insurance plans that cover eligible medications. Patients who have insurance coverage for eligible medications or participate in federal or state programs are required to notify ReUnite Rx immediately. 4) ReUnite Rx discounts and rebates are not available in combination with any other rebate or discount offering. 5) ReUnite Rx discounts can only be applied to prescriptions filled after the qualification date. ReUnite Rx will not consider any discounts if the applicant has already purchased eligible medications. 6) Limitations for use and quantity of eligible medications are at the sole discretion of ReUnite Rx. 7) Minimum age to qualify is 18 years old. 8) Void if prohibited by law, taxed, or restricted. 9) This card has no cash value. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 10) By redeeming and/or using ReUnite Rx, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer. ReUnite Rx is not insurance.
