Omnitrope Consent Form
OmniSource® is a comprehensive support center dedicated to helping eligible patients prescribed Omnitrope. The people at OmniSource® are committed to answering your nonmedical questions, helping to facilitate the insurance process, providing a starter kit when insurance coverage is approved, and coordinating injection training with an OmniSource® nurse if the prescribing doctor requests it.
Please read this entire form and complete in the spaces indicated.
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Sandoz Inc. understands your personal and health information is private. By providing consent on this form, you are authorizing the release of your personal protected health information for patient support services. The personal information we collect from you will be used to bring you information about products, programs and services, to conduct market research, and as provided in our Privacy statement. Please be assured that although we share your personal information with our business partners who work with us on these activities, we do not permit them to use your personal information for their own marketing purposes. The information you supply may be shared with your healthcare provider. If you have any questions about this release, please do not hesitate to call 877.456.6794. You may unsubscribe from our programs and services at any time by calling 877.456.6794. For more information about our privacy practices, please visit our website at www.us.sandoz.com/util/privacy_policy_us.shtml.