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. CloudRx Pharmacy, LLC (“CloudRx Pharmacy”) 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 CloudRx Pharmacy 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 CloudRx Pharmacy. 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 CloudRx Pharmacy and its affiliates, agents, representatives, and service providers. I understand that I may withdraw my authorization in writing by contacting CloudRx Pharmacy 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 CloudRx Pharmacy to send me correspondence via email or text messaging.