Pharmacy Savings Program

HIPAA Authorization

Terms. This pharmacy savings program (The Pharmacy Savings Program), is administered by Medical Security Card Company (MSC), LLC of Tucson, Arizona. In administering the Pharmacy Savings Program, MSC receives individually identifiable health information (including, but not limited to the information provided on this enrollment form) from the participating pharmacy, Pharmacy Savings Program transactions or directly from you. Your authorization is required as a condition of enrollment in the Pharmacy Savings Program as MSC must have this information to administer its point-of-sale discount prescription service. The individually identifiable health information provided to MSC and the participating pharmacy is not transferred, sold or otherwise disclosed to third parties, except as necessary for the proper administration of the Pharmacy Savings Program or as may be otherwise required by law, and is always protected as Confidential Private Information. To view the MSC Privacy Policy, please visit:

Authorization. I understand that by checking the box on the previous page, I agree that this constitutes my written authorization for MSC to receive and use the individually identifiable health information described above for the proper administration of the Pharmacy Savings Program and for marketing purposes in accordance with applicable law. This authorization shall remain in effect for the duration of my enrollment in the Pharmacy Savings Program. I have the right to revoke this authorization in writing at any time by contacting Medical Security Card Company, LLC at 4911 E. Broadway Boulevard, Tucson, AZ 85711, except to the extent that my medical information has already been used or disclosed in reliance on this authorization. However, because this information is essential to the administration of this program, my revocation of this authorization shall result in cancellation of my enrollment in the Pharmacy Savings Program. If you are agreeing on behalf of dependent family members, your agreement verifies that you are the parent/legal guardian or the authorized representative of the individual identified on the enrollment form.