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SIGN UP TO RECEIVE INFORMATION ABOUT CHRONIC HEPATITIS C (HEP C),
MAVYRET, AND MAVYRET PATIENT SUPPORT

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DO YOU HAVE A MAVYRET PRESCRIPTION?

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ENROLLMENT PRIVACY NOTICE

MAVYRET Patient Support is an AbbVie-sponsored program that provides personalized patient support (“MAVYRET Patient Support”). AbbVie, its affiliates, collaborators and agents (“AbbVie”) will use your personal information, including your health information, collected through your enrollment and participation in MAVYRET Patient Support to: (1) provide you with MAVYRET related support and communications; and (2) perform research and analytics.

For more information about AbbVie’s privacy practices or how to opt-out of AbbVie marketing communications, visit  www.abbvie.com/privacy.html.




THANKS FOR REGISTERING!

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Have you been treated for hep C before?



Tell us more about your MAVYRET prescription


HAVE YOU BEEN DIAGNOSED IN THE LAST 12 MONTHS?


ARE YOU READY TO START TREATMENT?


HAVE YOU SEEN YOUR DOCTOR FOR HEP C IN THE PAST 12 MONTHS?


DO YOU HAVE HEALTH INSURANCE?

Understanding the type of coverage you have can help us provide the information and support you need




AUTHORIZATION OF RELEASE OF PROTECTED HEALTH INFORMATION (OPTIONAL)

I authorize my healthcare providers, pharmacies, insurers, and testing laboratories (my “Healthcare Companies”) to disclose information about me, my medical condition, treatment, insurance coverage, and payment related to my use of AbbVie products (“Personal Information”), to AbbVie, its affiliates, collaborators, and agents (collectively “AbbVie”), to provide me with AbbVie-sponsored patient support and for AbbVie’s analytics and research purposes. Personal Information released under this Authorization is subject to re-disclosure by AbbVie and will no longer be protected by HIPAA. My Healthcare Companies may receive remuneration from AbbVie for disclosing my Personal Information to AbbVie and contacting me about my use of AbbVie products and services. I am not required to sign this Authorization and my Healthcare Companies will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization. This Authorization will expire in 10 years or a shorter period if required by state law, unless I cancel it sooner by calling 1-877-628-9738, or by writing AbbVie Customer Service, Department 36M, 1 N. Waukegan Road, North Chicago, IL 60064-6163. Cancelling my Authorization will not affect uses of my information that occurred before my cancellation was received.

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