Prescription Savings Card

Information Disclosure Authorization

Welcome to the QualityHealth Prescription Savings Card. By completing and submitting your registration, you hereby agree to the terms and conditions outlined here and authorize the collection, use, and disclosure of health information about yourself, including information you provide during your registration for the QualityHealth Prescription Savings Card program, and information about the prescriptions you buy using the QualityHealth Prescription Savings Card (which may include information about: mental health, human immunodeficiency virus, acquired immune deficiency syndrome, genetic testing, drug/alcohol diagnosis, treatment and/or referral). By completing and submitting your registration, you authorize QualityHealth to receive information from your pharmacy and companies that help offer this program. QualityHealth will not sell your information to any third party for its own commercial purposes. You understand that QualityHealth will use collected information to administer the Prescription Savings Card program, to evaluate the effectiveness of the program and of QualityHealth's marketing campaigns, and to communicate general and administrative information to you about membership in the program using electronic and/or postal mail. QualityHealth will only share collected information with service providers who provide support for QualityHealth's ongoing operations, and in accordance with contracts from those service providers who agree to use collected information in the manner described here, and as otherwise required by law.

By completing and submitting your authorization, you agree that: 1) You understand registration and participating are voluntary. You understand that you may refuse to agree to this authorization, but should you do so, you will not be able to participate in the program. 2) You understand that by completing and submitting your registration, you are voluntarily authorizing to share with QualityHealth the information described above. Understand that this information is typically protected by federal privacy regulations, but when you are give permission for its use to any company or organization, it may not be protected by the same regulations. Know that your privacy is very important to QualityHealth, and that QualityHealth will take every measure possible to protect it. 3) You may revoke this authorization in writing at any time. Any action has already been taken in accordance with this authorization, if not revoked earlier, will terminate when you cease to participate in the program. Any revocation will not apply to information that has already been used and released in response to this authorization.

By completing and submitting your registration, you acknowledge that you are the individual whose information will be used and released, or that you are authorized to act on that individual's behalf. You acknowledge that you have read the above and authorize the use and disclosure of the information as stated.