I authorize (i.e., allow) the use and/or disclosure of my Protected Health Information, described below, which is protected under a federal law known as the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”). In general, Protected Health Information is information, including demographic information, which (1) relates to my past, present, or future physical or mental health or condition, the provision of health care to me, or the past, present, or future payment for the provision of health care to me, and (2) that identifies me or for which there is a reasonable basis to believe can be used to identify me. I understand that this authorization is voluntary.

1. Person(s) or Class of Person(s) Authorized to Disclose Protected Health Information: My health care providers, including my treating physicians and medical laboratories, that provide health care to me and conduct medical testing.
2. Person(s) or Class of Person(s) Authorized to Receive Protected Health Information: Pfizer Inc. (“Pfizer”), VynAssist Program (the “Program”) and other authorized service providers of Pfizer.
3. Description of Protected Health Information that may be Used and/or Disclosed: My name, patient identifier, test results, medical records, healthcare provider information, other data that identifies that I am seeking health care services, and data otherwise related to my health condition, diagnosis, and/or treatment.
4. Purpose(s) for the Use and/or Disclosure of Protected Health Information: To determine whether I have a valid Vyndamax (tafamidis) prescription and other conditions for eligibility under the Program have been met.
5. No Conditioning. I understand that my health care providers may not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.
6. Right to Revoke. I may revoke (i.e., take back) this authorization at any time, except to the extent that my health care providers have taken any action in reliance on my authorization. I understand that if I revoke this authorization, it will not have any effect on any uses or disclosures of my Protected Health Information that occurred prior to receiving my revocation. To revoke this authorization, I must inform my Pfizer Patient Access Coordinator (PAC). I understand that the revocation will only be effective once received by the PAC.
7. Expiration of Authorization. This authorization will remain in full force and effect for one year from the date of this authorization, unless I revoke it prior to this time.
8. Potential for Re-disclosure. Persons or entities that receive my Protected Health Information under this authorization may not be required by privacy laws (such as HIPAA) to protect the information and they may share it with others without my permission, if permitted by laws that are applicable to them.
9. Copy of Authorization. I understand that I am entitled to receive a signed copy of this authorization.