Egrifta SV Consent Form

Patient Authorization to Use and Disclose Protected Health Information

I authorize health care providers and their staff involved in my care to disclose my Protected Health Information (as defined below), including but not limited to my medical record and other health information on my completed Statement of Medical Necessity form or other forms, records that may contain information created by other persons, entities, physicians, and health care providers information concerning HIV/ AIDS diagnosis and treatment, including HIV test results, as well as information regarding substance use disorder treatment services and mental health services (excluding psychotherapy notes) (collectively, “Protected Health Information”), to Theratechnologies Inc. and its agents, representatives, and direct and indirect service providers (collectively, “Theratechnologies”), so that Theratechnologies may:

1. Facilitate the filling of my prescription for and the delivery and administration of Theratechnologies products, including disclosing or redisclosing Protected Health Information to pharmacies;
2. Assist me in obtaining insurance coverage for Theratechnologies products, including disclosing or redisclosing Protected Health Information to health plans;
3. Partner a Nurse Navigator to contact me for training and adherence assistance. Interaction can be live audio/video training offering education for proper use, if appliable, administration and continuous adherence guidance. I have the right not to be recorded at any time. Theratechnologies will have access to my communications to provide adequate patient care. Any dissemination, storage or retention of an identifiable patient image or other information shall comply with federal and state laws and regulations requiring confidentiality;
4. Create deidentified and aggregate information to be used and shared for reimbursement, publication, or commercial purposes.

I authorize Theratechnologies to contact me by mail, email, video and/or telephone to enroll me in, and administer programs that provide support services.

To accomplish these purposes, I further authorize Theratechnologies to share information, including HIV/AIDS information, between and among the entities defined in this Authorization as Theratechnologies.

I understand that once my Protected Health Information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy law and regulations known as “HIPAA” or state privacy laws and may be the subject to further disclosure by Theratechnologies and third parties with whom Theratechnologies may share the information. However, other state and federal laws may prohibit the recipient from disclosing specially protected information such as certain HIV/AIDSrelated information, substance use disorder treatment information, and mental health information. I understand that I may refuse to sign this authorization. My refusal will not affect my ability to receive Theratechnologies products, treatment, payment, enrollment in a health plan, or eligibility for benefits but my refusal may limit my ability to receive certain support services that are provided by Theratechnologies.

I understand that health care providers may receive compensation, remuneration, or other value as a result of their use and disclosure of my Protected Health Information as described in this authorization.

I understand that this authorization will remain in effect for 10 years from the date of my signature, unless limited by state laws and regulations and/or I revoke it in writing by contacting Theratechnologies c/o

ASPN Pharmacies, LLC
290 West Mount Pleasant Ave
Building 2, 4th Floor, Suite 4210
Livingston, NJ 07039 United States

If I revoke this authorization, Theratechnologies and any third parties that are notified of my revocation will stop using my Protected Health Information for the purposes outlined in this authorization, but the revocation will not affect prior use or disclosure of my Protected Health Information in reliance on this authorization. I have the right to receive a copy of this authorization after I sign it.

I understand that the support services provided by Theratechnologies that are described in this authorization can be changed at any time, without prior notification.

By checking this box, * I authorize Theratechnologies to:

• Send me text messages about my EGRIFTA SV® order to the phone number. I understand that standard data fees and text messaging fees may apply based on my mobile plan; and
• Provide me with free educational information and marketing materials; and
• Conduct surveys to measure my satisfaction with Theratechnologies products and services.