Something went wrong. Please try again later.
Email Id is invalid
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.
Please provide appropriate value in each field's default value property as per Analytics Tech Specs
Form Name:
Form Category:
Account Management, Contact, Interactions, Quiz, Registration, Services
Form Sub-Category:
Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story
Form MVA Name:
Form MVA Type:
Download, Form, Link, Share, Tool, Video
Form MVA Tier:
Form MVA Category:
Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other
Form PII Field Names for Masking:
Form Analytics Payload: