PATIENT: United RX Prescription Advocacy Program offers patient assistance programs and processing assistance to help patients who qualify for certain medications at no cost. In order to determine your eligibility for the program and to administer your participation in the program if you are accepted. Prescription Assistance program needs to obtain certain information about you from your doctor. Please complete this authorization form.
HEALTH CARE PROVIDER: Please retain this signed authorization with the patient’s records. You do not need to return this
authorization to United RX Prescription Advocacy Program.
I request and authorize my provider to give United RX Prescription Advocacy Program, including management and staff, information about me and my medical conditions, which is necessary to determine my eligibility for the program and for my continuing participation in the program if I am accepted and to administer the program. The type of information that can be given under this authorization may include;
- My name and date of birth.
- My address and telephone number.
- My social security number.
- Financial information about me.
- Information about my health benefits or health insurance coverage.
- Information on my medical condition, as necessary.
- Information about my medication use.
I know that I can cancel this authorization at any time by writing to my provider at
. If I cancel this authorization, my doctor will stop providing Prescription Assistance Program, including its management and staff, information about me.
This authorization will expire upon notice by the patient or health care provider working on the behalf of the patient.
Patient of Personal Representative of Patient
