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Information Disclosure Authorization

By completing and submitting your registration and clicking below, you acknowledge and agree that:
1) Your registration and participation are voluntary, and that you may refuse this authorization to not participate in the program.
2) You are voluntarily agreeing to allow the collection, use and disclosure of health information about you as described below.

As part of the program, QualityHealth will collect, use, and disclose certain information, including information you provide during registration, and information about the prescriptions you buy using your 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) in order to administer the program, evaluate the effectiveness of the program and marketing campaigns, and to communicate general and administrative information to you about membership. This information is typically protected by federal privacy regulations, but by authorizing its use and disclosure, it may not be protected by the same regulations.

QualityHealth will never sell your Protected Health Information to any third party for its own commercial purposes, and, unless otherwise required by law, will only share Protected Health Information in accordance with contracts where service providers agree to use the information as described in this Authorization.

  • By signing this Authorization below, you understand: You are the individual whose information will be used and released, or that you are authorized to act on that individual’s behalf,
  • You may revoke this Authorization in writing at any time.

I have read and agree to the Information Disclosure Agreement.
*Conditions: These promotions are brought to you by and are subject to the following:
Participants must 1) register on; 2) be 18 years or older; 3) provide verifiable registration information such as: valid age, email address, shipping address, etc; 4) agree to the Information Disclosure Authorization.

Please ensure to provide a valid email address. An email will be sent to you containing your Prescription Savings Card codes and a link to your card online.
Consumers not covered by health insurance will benefit most from this prescription savings program.
YOUR PRIVACY IS IMPORTANT TO US. By submitting your information to QualityHealth, you are agreeing to receive emails and/or direct mail from time to time containing personalized health content, targeted advertising, opportunities to participate in market research surveys and other offers from QualityHealth and our partners. From time to time, with your explicit consent, we may share your contact information directly with our partners to facilitate this process. For more information, please click here to review our privacy policy.