Afrezza Assist

Patient Authorization
By signing below, I authorize my healthcare providers (including those pharmacies that may receive my prescription for AFREZZA), to disclose personal health information (“PHI”) about me, including health information relating to my medical condition, prescription, and insurance coverage, to MannKind Corporation and its employees, affiliates, contractors and agents, including their third party patient support program service provider hired to administer the AfrezzaAssistSM Program (collectively “MannKind”) in order for MannKind to (1) enroll me into the AfrezzaAssistSM program; (2) communicate with my healthcare providers and health plans about my treatment plan; (3) provide support services including patient education, product training, and adherence-related communications for AFREZZA. I authorize MannKind to use my personal information for the purposes listed above, as well as to contact me for reasons related to the AfrezzaAssistSM program and support services, to obtain further information or clarification regarding any adverse event I may experience, and to conduct market research regarding AFREZZA and MannKind’s products and services. I authorize MannKind to disclose that I am on AFREZZA therapy in voice-mail messages left for me related to the AfrezzaAssistSM program. I understand that once my PHI has been disclosed to MannKind, it may no longer by protected by federal privacy law and could be re-disclosed to others but that MannKind intends to use and disclose my PHI received pursuant to this authorization only for the purposes described above or as required by law. I would also like to receive information from MannKind via mail or email, which may include disease state, educational material to support patients, and information about AFREZZA. I agree to be contacted by autodialed text messages (“texts”), placed by MannKind or its agents or service providers (collectively, “MannKind”) to the mobile phone number I have provided below, for the purpose of helping me stay informed of the AfrezzaAssistSM process and helping me stay on therapy. I certify that the number I am providing belongs to me and not a family member or third party. I understand that I may opt out of receiving such messages at any time by calling 1-844-323-7399 or replying “STOP” by text to any text from MannKind or AfrezzaAssistSM and that my consent to being contacted by text messages is not a condition for me to purchase any products or services. I understand that I can withdraw this authorization by calling AfrezzaAssistSM at 1-844-323-7399 or mailing a letter with my notice of revocation to AfrezzaAssistSM, 4700 Hanley Road Building #6, Berkeley, MO 63134. I understand that if I do revoke the authorization, it will thereafter be invalid, but that uses and disclosures made in reliance on the authorization prior to its revocation will not be invalidated. I understand that my treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits will not be directly affected if I do not sign this Authorization. However, if I do not sign this Authorization, I may not be able to receive certain support services from MannKind. This authorization expires five years after the date I sign it below. I understand that I am entitled to receive a copy of this authorization. I understand my consent is not a condition of purchase.
Additional terms apply: SMS Terms: MannKind Privacy Policy: