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To activate or enroll online, please start by telling us about yourself below.

Are you currently taking VIBERZI®?

By activating your VIBERZI® savings card, you certify that you are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these types of programs at any time, you will no longer participate in this savings program.

I agree to this certification and I have read and accept the Program Terms, Conditions and Eligibility Criteria.*
Please check box if you agree

HIPAA Patient Access and Direct Disclosure Request

By clicking the “Accept” button below, I hereby request that my treating physicians, healthcare professionals, or other healthcare providers (collectively, my “Healthcare Providers”) disclose and transmit my protected health information to AbbVie and/or its designated service providers (collectively, “AbbVie”) in order for AbbVie to (i) provide me, or my physician, with communications about AbbVie’s savings card, if eligible, reimbursement assistance programs, drug verification, healthcare provider educator services, and adherence programs (“Program”); (ii) operate, administer, register me in, and/or provide me with access to the Program’s services; (iii) identify products and services that may be of interest to me and to provide me with communications about any such products and services; and (iv) develop, evaluate, and improve products, services, materials, and programs related to the Program or my condition or treatment. I understand that any healthcare providers participating in the Program will have access to my health information as part of the Program. I request that any protected health information disclosed by my health care providers pursuant to this request is transmitted electronically to a service provider in an encrypted file as required by the purposes stated above. This request is made pursuant to 45 CFR § 164.524.