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 care and treatment may be released as set forth on this
Form. Accordingly, I authorize Verrica Pharmaceuticals and its
agents, contractors and assignees, my insurance companies, my
healthcare providers, specialty pharmacies, and any vendors
contracted by such entities and the Y-Access Support Solutions
program to receive, use, and share my 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 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 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 my entire medical file, including but not
limited to my demographic information, diagnosis and treatment
information, prescription information, and financial information. I
understand and acknowledge that my healthcare providers may receive
remuneration for sharing my PHI if I sign this authorization.
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 understand that I am not required to sign this authorization as a condition of receiving treatment, payment, enrollment, or benefits from my healthcare providers, but I may not have access to certain of the Y-Access Support Solutions services.
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 receive YCANTH, as prescribed by my physician. 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. I certify that I am at least eighteen (18) years of age.
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).
I understand that I am entitled to receive a copy of this authorization once it has been submitted.
By submitting, I certify that I have read and agree to the above Patient Authorization.
