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AkebiaCares is a program administered by Akebia that provides
Patient Support to eligible patients who have been prescribed an
Akebia medication. Patient Support includes: (1) providing
reimbursement and assistance with financial support (including,
but not limited to, investigating insurance coverage, confirming
out-of-pocket costs, and reviewing eligibility for financial
assistance); (2) working with patients and their healthcare
professionals to fill their prescriptions; and (3) providing
patients with disease and medication-related educational
resources and communications.
I acknowledge that Akebia may use My Information and share it
with My Providers or My Plan in connection with providing
Patient Support and for the other purposes described in the
authorization above. I expressly permit Akebia to (1) contact me
or my representative, using contact information that I provide,
through any medium, including, but not limited to, mail,
telephone, text message, or email; (2) use My Information to
tailor AkebiaCares-related communications to my needs; and (3)
share information with My Providers about dispensing an Akebia
product to me. Akebia may also de-identify My Information and
use the de-identified information for Akebia's business
purposes. I understand that AkebiaCares is an optional program
and that my treatment, insurance enrollment, and insurance
eligibility are not conditioned upon providing consent. I also
understand that refusing to consent will make me ineligible to
participate in AkebiaCares. If I provide consent, I may revoke
it at any time by mailing a letter to AkebiaCares, P.O. Box
5490, Louisville, KY 40255, sending an email to
support@akebiacares.com, or following the opt-out instructions
in any correspondence that I receive. If my contact or insurance
information changes at any time while I am participating in
AkebiaCares, I will notify AkebiaCares as soon as possible by
using the physical or email address provided above. By signing
below, I confirm that I would like to enroll in AkebiaCares and
that I want Akebia to provide me with Patient Support. By
signing below, I also authorize the Centers for Medicare &
Medicaid Services to disclose Medicare eligibility information
to Akebia.
If I am applying for financial assistance, I also agree that
Akebia can use the information provided on this form or
otherwise provided by me directly or through My Providers
(including my Social Security number, household information, and
household income) to obtain credit reports about me from credit
reporting agencies in order to verify the information, estimate
my income, and determine my eligibility for financial
assistance. Regardless of whether a credit report is obtained,
Akebia has the right to require written proof of income (such as
a Form 1040, Form W-2, or other documentation) from me in
connection with a financial eligibility determination.
I understand that I may opt-out of these communications at any
time via the link/contact information available in all
communications.
§ The authorized patient representative may not
be the patient's healthcare professional.
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