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Applicant Declaration and Consent

Applicant Declaration and Consent (English Version)

Applicant Declaration and Consent (Spanish Version)

Applicant Declaration:

You attest and certify to Good Days and its agents that the information provided in your application is complete and accurate. You understand that, and consent to, your reported financial information being verified by an audit as deemed necessary by Good Days. Good Days, and its authorized third party agents, such as credit monitoring companies, may use your demographic information, including but not limited to your social security number, date of birth, name, and address in order to estimate your income in conjunction with the eligibility process. You understand that Good Days, and its authorized third party agents, reserve the right to ask for additional documents and information at any time. As a soft credit inquiry, this does not impact your credit score.

You further understand that any false or incomplete information provided by you to Good Days could unduly harm your application process, Good Days, its reputation, and its tax exempt status. You also understand that any financial assistance provided to you by Good Days may be recouped, if Good Days becomes aware of any inaccurate information or fraudulent activity relating to your application or the assistance provided to you.

You understand that you are not guaranteed or promised assistance. Any assistance Good Days may provide is limited to the terms and conditions established by Good Days. Good Days reserves the right at any time, and for any reason without notice, to modify the eligibility criteria or modify or discontinue any assistance.

Terms of the Consent Pertaining to the Disclosure of your Personal Information:

In order for you to receive assistance through Good Days, you authorize your physicians, pharmacies and insurance companies to disclose to Good Days and its applicable contractors, employees, agents and other representatives your personal information. In addition you authorize Good Days to use and disclose your personal information to Good Days’ agents, third parties acting on its behalf, credit monitoring companies, or any of your healthcare providers.

Your personal information may include, but not be limited to, your name, address, phone number, email address, date of birth, social security number, insurance status and numbers, amount of financial assistance allocated and dispensed, diagnosis information, and treatment information.

You consent to the disclosure of your personal information (i) to enable Good Days to determine whether you are eligible and qualify for financial assistance for any medication(s); (ii) to enable Good Days to provide financial assistance to you for your medication(s); (iii) to refer you to, or to determine your eligibility for, other programs, foundations or alternate sources of funding or coverage for your healthcare costs, products and services; (iv) to facilitate the audit or review of Good Days’ operations; and (v) to enable Good Days to manage its patient assistance programs.

You understand that your personal information that is disclosed may be re-disclosed by the recipient and no longer protected by federal or state privacy regulations and laws. You consent to Good Days electronically disclosing your personal information to third parties as permitted or required by law.

You may revoke this consent at any time by mailing a signed letter of revocation to Good Days’ Privacy Officer at 6900 Dallas Parkway, Suite 200, Plano, TX 75024 or faxing the written revocation to Good Days’ Privacy Officer at the following fax number: (214) 570-3636. Revoking this consent will not have any effect on actions that Good Days took in reliance on the consent before it received notice of your revocation. If you revoke this consent, you will not be able to receive future assistance through Good Days.

This consent expires six years from the date that you last receive assistance from Good Days, if not revoked sooner.