b'BIOPLUS SPECIALTY PHARMACY PATIENT GUIDEBOOKI intend by this assignment and designation of authorized representative to convey to the pharmacy all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or medications provided by the above-named healthcare provider, including rights to any settlement, insurance, or applicable legal, equitable, or administrative remedies (including damages, remedies, and civil penalties arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (Pharmacy) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make state-ments about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose inaction or right against any liable party, insurance company, employee benefit plan (self-insured or fully-insured), healthcare benefit plan, or plan administrator. The pharmacy as my assignee and my designated authorized representative may bring suit against any such healthcare benefit plan, employee benefit plan, plan administrator, or insurance company in my name with derivative standing at providers expense.This assignment is irrevocable and valid for all administrative and judicial reviews under PPACA (healthcare re-form legislation), ERISA, Medicare, and applicable Federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.I understand that I may contact the pharmacy at the number on my prescription label with any questions regarding this form.I HAVE READ AND FULLY UNDERSTAND THIS CONSENT TO THERAPY.Patient Name (Patient): _____________________________________________________________________Patient Signature: ____________________________________________________________________________Date:_____________________________________________________________________________________Rev. 1/202431'