Home
Forms Library
Sanofi hipaa consent form

Sanofi hipaa consent form 2025

sanofi hipaa consent form Preview on Page 1

See details

4 out of 5

47 votes

The document is an application form from Sanofi Patient Connection, designed to assist patients in accessing no-cost medications and additional resources. It includes sections for patient information, treatment details, prescriber information, and eligibility criteria for various assistance programs. The form requires signatures from both the prescriber and the patient, along with income verification options to determine financial eligibility for assistance.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out sanofi hipaa consent form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the sanofi HIPAA consent form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's first name, last name, date of birth, and contact details. Ensure accuracy as this information is crucial for processing.
Proceed to 'Treatment and Prescribing Information'. Specify the prescribed drugs, their quantities, and refills needed. This section is vital for ensuring the patient receives appropriate medication.
In 'Prescriber Information', input details about the prescriber including their name, license number, and contact information. This verifies that a licensed professional is overseeing the patient's care.
Complete the 'Resource Connection' section by indicating if the program can contact the patient regarding additional resources. Mark any relevant interests for support services.
Finally, ensure both patient and prescriber sign where indicated. This confirms consent and authorizes information sharing necessary for program participation.

Start using our platform today to easily complete your sanofi HIPAA consent form online for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the purpose of HIPAA?

HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs.

What is the Sanofi patient support program?

Medications Available Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine Absorbed. Admelog ( lispro) injection 100 Units/mL. ( glulisine) injection 100 Units/mL. (rasburicase) IV infusion. RABIES Rabies Vaccine (Human Diploid Cell)

What is a HIPAA consent form?

Sanofi Patient Connection is an access and support program in the U.S., providing medication at no cost to eligible patients, helping patients understand their insurance coverage, and identifying additional resources patients may find helpful.

What is an example of a HIPAA authorization?

I hereby authorize use or disclosure of protected health information about me as described below. 4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

What is a HIPAA compliant form?

A HIPAA release form is a document that when signed allows healthcare providers to share a patients protected health information (PHI) with specified individuals or organizations, according to the details stipulated in the form.

What is HIPAA consent?

Obtaining consent (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations) is optional under the Privacy Rule for all covered entities.

Sanofi hipaa consent form 2025

Here's how it works