BOTOX® Savings Program Disclosure
In order for me to participate in Allergan’s BOTOX® Savings Program, I authorize my health care provider and its
agents, as well as other health care providers who may have relevant information for my participation in the
BOTOX® Savings Program, to release and disclose to Allergan and Allergan’s agents operating the BOTOX® Savings Program,
the medical information located in my medical record. This information may include, but is not limited to, my name, address, email address,
treatment dates, eligible treatment type and product information, prescription information, including dosage and refill information,
and personal information that is used to communicate with me about eligibility, claim status, payment, and other relevant information.
My provider may release this information in whatever form and through whatever media the BOTOX® Savings Program requires,
including the Internet.
I understand that this information will be used by Allergan and its agents that operate the BOTOX®
Savings Program to administer the Program, verify my eligibility, process claims, authorize payments, perform other operational functions,
and communicate with me about my use of the BOTOX® Savings Program.
1) I further understand that because Allergan and its agents are not covered by federal privacy regulations, after my information is disclosed
to Allergan and/or its agents, it will no longer be protected under federal law and could be subject to re-disclosure. Once disclosed to Allergan and/or
its agents pursuant to this authorization, the information will, however, be treated as confidential and will be used and protected by Allergan and/or
2) I understand that I may revoke this authorization at any time, but my revocation will not apply to information that has already been released
by my health care provider before Allergan receives notice of the revocation. I should send revocations in writing to my health care provider
noted in Step 5, or as otherwise directed by my health care provider.
3) I understand that this authorization is voluntary and I may refuse to sign it. While I understand that my refusal to sign this authorization
will not affect my ability to obtain treatment or payment for my treatment, by refusing to sign, I may be ineligible to participate in the
BOTOX® Savings Program.
4) I will receive a copy of this authorization by submitting a request to my health care provider as noted above. I hereby represent that I am the
patient whose name is set forth in Step 1 and that I have all necessary rights and authority to submit this electronic authorization
and agree that my medical information may be used and disclosed as set forth above.
5) I understand that by providing and submitting the above data and this consent on this website, I am providing and executing this authorization electronically.
This authorization expires on December 31st following the date this authorization in signed.
By clicking submit, I acknowledge that I understand and agree to the above.