You are enrolling your patient into the SPIRIVA RESPIMAT Hospital to Home program.
All fields are required unless otherwise noted.
The Hospital to Home Program (the “Program”) includes various offerings, including, patient education, and general adherence support. The Program is funded by Boehringer Ingelheim Pharmaceuticals, Inc. and its affiliates and subsidiaries (collectively, “BIPI”) and is administered in conjunction with certain of its contractors and agents and clinical education contractors (collectively, the “Contractors”).
By checking here, I am authorizing BIPI and its contractors to use the information provided on this form to enroll me in the Hospital to Home program and mail me customized education materials.
By checking here, I am authorizing BIPI to use the information I provided to mail or email me health- and product-related information, including marketing/offers about other BIPI products. If at any time I change my mind regarding participation in the selected program offerings, I understand that I can opt out by contacting Hospital to Home at 844-666-1630 anytime.
Please have the patient read the following HIPAA Authorization.
I understand that the information contained on this form, including my contact information, as well as any other information necessary for my participation in the Program (collectively, “Personal Information”) may contain or otherwise be viewed as a form of “protected health information” as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (“HIPAA”).
I understand and agree that:
PATIENT, by typing your full name in this box and providing either an email address or phone number, this serves as your electronic signature and acceptance of this HIPAA authorization.
Please see full Prescribing Information, including Instructions for Use, for SPIRIVA RESPIMAT.