Authorization for Use and Disclosure of Information
1. Information to be Used and Disclosed. I authorize the entities comprising the NES Assurance, LLC (DBA IVF-Connect)
to use and disclose to affiliates of NES Assurance and IVF-Connect the information I provide and is collected during my interactions with NES Assurance and IVF Connect, including: name, date of birth, address, telephone number(s), e-mail address, medical information, prescription and prescription-related information, and pharmacy name and other contact information. If my medical information, prescriptions
and/or prescription-related information disclose information regarding any sensitive medical conditions I may have, including but not limited to those related to mental health, substance use, HIV or other communicable diseases, developmental disabilities, and/or genetic conditions, I authorize that information to be used and disclosed pursuant to this Authorization.
2. Purpose. The purpose of this Authorization is to: (a) permit NES Assurance to use and disclose my information for marketing purposes, including contacting me at my contact information saved in my profile to provide me with marketing and promotional messages about Affiliates’ products and services, including but not limited to, prescription pricing and coupons, savings offers, refill reminders, and marketing and promotional messages about other pharmacy,
pharmaceutical, medical, or laboratory services, either provided directly by Affiliates or by companies that may otherwise partner with NES Assurance and (b) inform you that NES Assurance and/or Affiliates may receive direct or indirect compensation in relation to such marketing. I understand that either NES Assurance and/or Affiliates may contact me using my contact information for these purposes.
3. Your Rights. I understand that this Authorization is voluntary. I may revoke this Authorization by sending a request to admin@nesassurance.com, except to the extent that action has been taken in reliance upon my Authorization. I understand that information used or disclosed as a result of this Authorization may be
subject to re-disclosure by Affiliates and may no longer be protected by applicable privacy laws. I understand that NES Assurance may not condition treatment, payment, enrollment or eligibility for benefits on your execution of this Authorization. I understand that if I agree to this Authorization by checking the related box, which I am not required to do, I can obtain a copy at any time by sending a request to admin@nesassurance.com
4. Expiration. This Authorization will remain in effect as long as I obtain services from NES Assurance or until I revoke it, whichever occurs first.
By signing this Authorization or by checking the related box, I am authorizing the use and disclosure of all information as outlined above.