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By completing and submitting this form, I authorize Ferring and its agents to enter certain information I have provided relating to the treatment of my medical condition (or the person for whom I am legally authorized to serve as guardian) into a database. This may also involve the use and/or disclosure of my private health information, described below, which includes “Protected Health Information” or “PHI” as defined by a federal law known as the Privacy Rule developed under the Health Insurance Portability and Accountability Act of 1996, which was amended by the Health Information Technology for Economic and Clinical Health Act (as amended, “HIPAA”). In general terms, I understand that PHI is health information that identifies me or that could reasonably be used to identify me. I understand that this authorization is voluntary. I also understand that my health care professional or provider may not condition (i.e., withhold or refuse) my medical treatment, payment, enrollment in a health plan or eligibility for benefits if I refuse to provide this authorization. I agree that Ferring, its agents, subcontractors, affiliates, or third parties under contract with them, or my treating physician may use the information provided by me and contact me from time to time by telephone, mail, or email to provide information about products or services related to my treatment that may be of interest to me such as enrollment status, insurance benefits investigation, and drug product shipment. I understand that the information will be treated confidentially and will be accessed only by Ferring authorized personnel or third parties under contract with Ferring or its affiliates. I have a right of access and verification to my personal information. I also have a right to opt out of the database at any time. Subject to the above, unless authorized by me, my personal information will not be sold or transferred to third parties, other than in the event of Ferring or its affiliates being sold. If you no longer wish to receive such communications from Ferring, you may “opt out” at any time by calling Ferring at 1-888-FERRING Monday through Friday, 8:00 a.m. to 7:00 p.m. EST to speak to a representative or leave a voicemail. This statement may be updated from time to time.

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Where to find us

Ferring Pharmaceuticals Inc.
100 Interpace Parkway
Parsippany, NJ 07054