Important - Action Needed
Prescriber signature required (or representative authorized by Prescriber)
ASPN Patient Support has received prescriptions for one or more of your patients. In order to provide manufacturer sponsored
patient support services including identifying and applying any copay assistance as well as verifying your patients’ benefit
coverage, please enter the signature:
Clear Signature
By signing above, I enter this agreement with ASPN for services on these terms and conditions:
ASPN will act as my agent for purposes of obtaining prior authorizations, conducting benefits investigations, verifying the accuracy of information provided, determining patient
eligibility for manufacturer programs, and other related services. Acting as my designated agent, ASPN may disclose my patient’s protected health information as needed to
provide the previously listed services. I will allow ASPN to contact me regarding prescription status updates. I understand that neither I nor the patient should seek reimbursement
for any free product received under any programs for which I have submitted a prescription and enrollment to ASPN.
As the Prescriber, I understand and acknowledge that:
Any forms (electronic or otherwise) or access to form libraries or other resources provided by ASPN for any purpose whatsoever, regardless of the mode, are provided
"as is," and all warranties are disclaimed. ASPN's sole liability to the prescriber for any claims of any type arising from the use of the forms shall be to correct any errors or
omissions. Such resources and their availability may be expanded, supplemented, replaced, discontinued, or altered in any way by ASPN in ASPN's sole discretion.
It is my responsibility to, and I will confirm the accuracy of the prescription and medication history with my patients before providing medical services. I shall use my
professional judgment when providing care.
I will not be permitted to access certain ASPN's data sources. Data sources provide patient-related information.
If I also maintain a pharmacy operation, I will retain any information received from ASPN on a partitioned server on the non-pharmacy side of an internal firewall that
is separate or "walled off" from all other pharmacy activities.
ASPN may update this Agency Agreement from time to time by sending written notice with the changes, which shall be binding on the parties ten (10) days after receipt
unless otherwise indicated on the notice.
I agree to comply with all applicable state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996 and its implementing
regulations, as amended ("HIPAA"). Any prescription that I send to ASPN will only be the result of a valid patient relationship, is medically necessary, and compliant with
applicable requirements. Prior to sending prescriptions to ASPN, I will obtain from my patients, as applicable, all required privacy and patient consents or authorizations to
disclose all patient health and other personal information to ASPN and its agents and representatives. I will notify ASPN if a patient revokes their consent or authorization.
I acknowledge and agree that neither ASPN nor its data sources are liable to me as the prescriber or the patient for the accuracy or completeness of any data provided in
connection with this agency agreement. I release and hold harmless ASPN and its data sources from and against all liabilities or causes of action or claims related to the data
completeness or lack thereof, or related to my reliance on the prescription benefit or medical history information.
I acknowledge that this agency agreement is effective from the date executed above and shall remain in full force and effect until terminated by me or ASPN by providing at
least thirty (30) days prior written notice to the other party.
