*Have you ever provided a patient an advanced prescription for Plan B®?
I understand that by completing this registration form, I am providing information that may be deemed personally identifiable information. I authorize Duramed Pharmaceuticals, Inc. to disclose my personally identifiable information to its affiliated companies and contractors, including Barr Laboratories, Inc. (collectively, “Affiliates and Contractors”), on a need-to-know basis for purposes of administering programs related to Plan B®. I understand that Duramed and its Affiliates and Contractors value their customers’ privacy. As such, Duramed and its Affiliates and Contractors will take reasonable and appropriate measures to protect the information provided on this form from inappropriate disclosure. However, I also understand that this authorization permits Duramed and its Affiliates and Contractors to share my personally identifiable information with other individuals/entities that may not be bound ethically or by any privacy laws and that, once in their possession, my information could be used or re-disclosed for any purpose.
I understand that I may revoke this authorization, in writing, at any time by clicking here. I understand that only an electronic revocation will constitute an effective withdrawal of my authorization, and that any such revocation will not be effective with respect to disclosures made by Duramed or its Affiliates or Contractors prior to receipt of the revocation by Duramed.
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