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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 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 1-877-628-9378, 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.


ENROLLMENT PRIVACY NOTICE

I understand that MAVYRET Patient Support is an AbbVie-sponsored program that provides personalized patient support. AbbVie, its affiliates, collaborators, and agents 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.

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