AUTHORIZATION FOR USE AND RELEASE OF PROTECTED HEALTH INFORMATION

ZENPEP® Patient Savings Program

I authorize Allergan and its contractors and business partners ("Allergan") to use and/or disclose my personal information, including my personal health information, for the following purposes: (1) to operate, administer, enroll me in, and/or continue my participation in the ZENPEP Patient Savings Program and/or any other Allergan-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs if eligible, reimbursement assistance programs, drug coverage verification, healthcare provider educator services, adherence programs, and disease management support); (2) to provide me with informational and promotional materials relating to Allergan products and services, and/or my condition or treatment; and/or (3) to improve, develop, evaluate, and continue Allergan products, services, materials, and programs related to my condition or treatment.

In order for Allergan to provide the above services and programs to me, I understand that Allergan will need my personal information and my health information, which may include my name, address, email address, information about my health condition, my treatment and product information, treatment dates, eligible treatment type, my medical history and general health, my healthcare plan benefits and coverage, information about my adherence to my treatment, and other relevant personal and health information ("Personal Health Information"). I authorize my healthcare providers, including my doctor's office, pharmacies, health plans, laboratory services, and other healthcare providers, and all employees, individuals, and entities working with or for such healthcare providers ("Healthcare Providers") who have my Personal Health Information to release and disclose my Personal Health Information to Allergan only for the purposes set forth above, including providing me with the ZENPEP Patient Savings Program.

I understand that some of my Healthcare Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Allergan in exchange for disclosing my Personal Health Information and/or for using my information to contact me with communications about Allergan products that have been prescribed to me and other patient support services.

My Healthcare Providers may release my Personal Health Information in whatever form and through whatever media, including the internet, as required by the purposes set forth.

I further understand that once my Healthcare Providers disclose my Personal Health Information to Allergan, it may no longer be covered by federal privacy regulations, and, therefore, could be re-disclosed. However, Allergan agrees to protect my Personal Health Information by only using and disclosing it as stated in this Authorization or as otherwise allowed or required by law.

I understand that I may receive a copy of this authorization or revoke this authorization at any time by calling (866) 800-8082. However, if I revoke this authorization, I understand I may no longer qualify for the ZENPEP Patient Savings Program and/or the other services described above. I further understand that if a Healthcare Provider is disclosing my Personal Health Information to Allergan, my revocation of this authorization will only prevent further disclosure of my Personal Health Information to Allergan by such Healthcare Providers after they receive notice of my revocation.

I understand that this authorization is voluntary and I may refuse to sign it. My refusal to sign will not affect my ability to obtain treatment or payment for my treatment. But, I may be ineligible to qualify for the ZENPEP Patient Savings Program and the other programs and services set forth above.

I understand that this authorization for my Healthcare Providers to disclose my Personal Health Information will not expire unless I notify Allergan to terminate it, or unless another date is specified herein, or is required by state or other applicable law(s).

Electronic Authorization:

I understand that by clicking the "I accept" button below, that I am consenting electronically and providing legal authorization for Allergan, including any affiliates, subcontractors, and/or agents of Allergan (such as vendors operating the ZENPEP Patient Savings Program) to use and share, and for my Healthcare Providers to disclose, my Personal Health Information for the purposes described within the above authorization. I am also indicating that I am at least 18 years old and either the patient or legal guardian of the patient by clicking the "I accept" button.