Y-Access™ Support Solutions is a service of Verrica Pharmaceuticals Inc. to facilitate healthcare provider and patient access to YCANTH™ (cantharidin) topical solution. I understand that health information regarding my patient’s care and treatment may be released as set forth on this Form. Accordingly, I authorize Verrica Pharmaceuticals and its agents, contractors and assignees, insurance companies, specialty pharmacies, and any vendors contracted by such entities and the Y-Access Support Solutions program to receive, use, and share my patient’s Protected Health Information (PHI) with each other for specific purposes related to prescriptions for YCANTH™ for the FDA-approved treatment of molluscum contagiosum to be administered by a healthcare professional.
I authorize the entities described above to receive, use, and disclose to one another my patient’s PHI in order to provide copay assistance, coordinate my benefits, provide reimbursement support, investigate my insurance coverage, help with financial assistance for YCANTH, provide patient and healthcare professional support services, ensure compliance with the requirements of the financial assistance services, and manage, administer, and/or support the Y-Access Support Solutions program and other business purposes. I understand that my patient’s PHI will not be used or disclosed for any other purpose without my prior authorization unless permitted by law or unless information that specifically identifies me is removed. The PHI to be shared may include the patient’s entire medical file, including but not limited to my demographic information, diagnosis and treatment information, prescription information, and financial information.
I understand that the PHI disclosed pursuant to this authorization, once disclosed, may not be governed by federal and state privacy law and may be subject to redisclosure.
I authorize Y-Access Support Solutions and the other entities described above to contact me to provide such services and information by mail, email, fax, telephone call, text message, and other means, including made by automatic telephone dialing systems or artificial or prerecorded voice. I further understand that I do not have to agree to receive the services and communications described above and that I can still prescribe YCANTH. I understand that I am under no obligation to purchase YCANTH. I understand that if I receive copay assistance, I cannot seek reimbursement for YCANTH from any government insurance program and that any financial assistance cannot be counted toward my true out-of-pocket costs. In addition, I confirm that I will only collect the remaining patient out of pocket costs, less the amount that I receive from Y-Access Support Solutions.
I understand that I may revoke this authorization by notifying a program representative by telephone at 1- 844-533-1069 or by sending a letter to 601 S Lake Destiny Dr. Suite 300, Maitland, FL 32751, but that such revocation will not be effective with respect to actions already taken in reliance on this authorization. I understand that if I do not cancel this authorization, the authorization will expire 24 months from the date of signature (or the maximum period allowed by applicable state law, if less than 24 months).
By submitting, I certify that I have read and agree to the above Provider Authorization.
