{"id":3073,"date":"2021-01-05T01:21:45","date_gmt":"2021-01-05T07:21:45","guid":{"rendered":"https:\/\/afrezza.com\/?page_id=3073"},"modified":"2024-03-13T08:43:23","modified_gmt":"2024-03-13T13:43:23","slug":"savings-program","status":"publish","type":"page","link":"https:\/\/afrezza.com\/savings-program\/","title":{"rendered":"AFREZZA SAVINGS PROGRAM"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row el_class=&#8221;container&#8221; css=&#8221;.vc_custom_1623705324289{padding-top: 30px !important;}&#8221;][vc_column css=&#8221;.vc_custom_1609322504173{padding-left: 0px !important;}&#8221;][vc_custom_heading text=&#8221;WELCOME TO THE AFREZZA SAVINGS PROGRAM*&#8221; font_container=&#8221;tag:h1|text_align:left&#8221; use_theme_fonts=&#8221;yes&#8221;][\/vc_column][\/vc_row][vc_row][vc_column][vc_empty_space height=&#8221;74px&#8221;][\/vc_column][\/vc_row][vc_row el_class=&#8221;container&#8221;][vc_column width=&#8221;1\/2&#8243; css=&#8221;.vc_custom_1609321043064{padding-left: 0px !important;}&#8221;][vc_custom_heading text=&#8221;REQUEST YOUR CARD NOW&#8221; use_theme_fonts=&#8221;yes&#8221;][vc_column_text]<strong>To obtain your Afrezza Savings Card, sign up below to register. You will receive your card via email or you can print a card.<\/strong><\/p>\n<p>If you have insurance, you may be eligible for the Afrezza Savings Card that lets you pay as little as $35 for your prescription.[\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_single_image image=&#8221;5380&#8243; img_size=&#8221;full&#8221; css=&#8221;.vc_custom_1710336636086{padding-right: 0px !important;}&#8221;][\/vc_column][\/vc_row][vc_row el_class=&#8221;container&#8221;][vc_column][vc_column_text]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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data-form-theme='legacy' data-form-index='0' id='gform_wrapper_13'>\n<div id='gf_13' class='gform_anchor' tabindex='-1'><\/div>\n<div class='gform_heading'>\n<h3 class=\"gform_title\">Tell Us About Yourself<\/h3>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_13' id='gform_13'  action='\/wp-json\/wp\/v2\/pages\/3073#gf_13' data-formid='13' novalidate>\n<div class='gform-body gform_body'>\n<div id='gform_fields_13' class='row gform_fields top_label form_sublabel_below description_below validation_below'>\n<div id=\"field_13_1\" class=\"form-group col gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_13_1'>Your First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container  ginput_container_text'><input name='input_1' id='input_13_1' type='text' value='' class='form-control small form-control-sm'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_13_2\" class=\"form-group col gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_13_2'>Your Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container  ginput_container_text'><input name='input_2' id='input_13_2' type='text' value='' class='form-control small form-control-sm'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_13_3\" class=\"form-group col gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_13_3'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container  ginput_container_date'>\n                            <input name='input_3' id='input_13_3' type='text' value='' class='form-control datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><br \/>\n                            <span id='input_13_3_date_format' class='form-control screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_13_3' class='form-control gform_hidden' value='https:\/\/afrezza.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_13_15\" class=\"form-group col gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_13_15'>ZIP Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container  ginput_container_text'><input name='input_15' id='input_13_15' type='text' value='' class='form-control large form-control-lg'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_13_4\" class=\"form-group col gfield gfield--type-phone gfield--input-type-phone gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_13_4'>Mobile Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container  ginput_container_phone'><input name='input_4' id='input_13_4' type='tel' value='' class='form-control small form-control-sm'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_13_5\" class=\"form-group col gfield gfield--type-email gfield--input-type-email gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_13_5'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container  ginput_container_email'>\n                            <input name='input_5' id='input_13_5' type='email' value='' class='form-control medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div>\n<\/div>\n<div id=\"field_13_6\" class=\"form-group col gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\">\n<div class=\"form-group\">\n<p class=\"label mb-0 mt-2 font18\">I understand that by completing this online form and checking the boxes below, I agree to MannKind its affiliates, business partners, and agents (\u201cMannKind\u201d) calling, emailing and\/or texting me using the contact information I have provided with communications relating to MannKind products and services and\/or my condition or treatment. MannKind may use automatic dialing machines or artificial or prerecorded messages to contact me and may leave a voicemail or SMS\/text messages (standard text messaging rates may apply). I understand that I am not required to provide consent as a condition of purchasing any goods or services. <\/p>\n<p>                  <a class=\"link-site sg-popup-id-2852 terms\" data-toggle=\"modal\" data-target=\"#termsandconditions\" data-popup-id=\"2852\">Privacy Policy<\/a> &nbsp;|&nbsp;                  <a class=\"link-site sg-popup-id-2852 terms\" data-toggle=\"modal\" data-target=\"#termsandconditions\" data-popup-id=\"2852\">SMS Terms and Conditions<\/a>             <\/p>\n<\/p><\/div>\n<\/div>\n<div id=\"field_13_7\" class=\"form-group col gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\">\n<style>\n.autherization-form p { padding-bottom:20px; }\n.autherization-form h3 { padding-bottom:30px; }\n.autherization-form p.font20 { padding-top:20px; }\n<\/style>\n<div class=\"autherization-form font18\" tabindex=\"0\">\n<h3>PRIVACY NOTICE AND AUTHORIZATION<\/h3>\n<h4>MannKind\u2019s Commitment to You<\/h4>\n<div id=\"form_section_1\">\n<div>\n<div>&bull; We do not and will not sell or rent  your information to marketing companies or mailing list brokers <\/div>\n<div>&bull; We will only collect and use personally  identifiable information for the purposes stated in this Authorization and as  necessary to provide the services and\/or programs into which each patient or  customer chooses to enroll <\/div>\n<div>&bull; Your enrollment and authorization is  completely voluntary and can be cancelled at any time <\/div>\n<div>&bull; We  take seriously our obligation to comply with state and federal laws that  protect your personally identifiable information, including your personal health  information <\/div>\n<\/p><\/div>\n<\/p><\/div>\n<p class=\"font20\"><em>Uses and Disclosure of Personal Information<\/em><\/p>\n<p>I authorize MannKind and its  contractors and business partners (&ldquo;MannKind&rdquo;) to use and disclose my personal  information, including my personal health information (&ldquo;PHI&rdquo;), only for the  following purposes:<\/p>\n<div>\n<div>&bull; To operate,  administer, enroll me in, and\/or continue my participation in MannKind&rsquo;s AfrezzaAssistSM  program or any other MannKind-affiliated patient support services and  activities related to my condition or treatment (e.g., co-pay card programs,  reimbursement assistance programs, drug coverage verification, product training  programs);<\/div>\n<div>&bull; To contact me by mail, email, SMS\/text  message, facsimile, telephone, and other means to enroll me in and administer  patient support programs and services and to provide me with free educational  information and materials; <\/div>\n<div>&bull; To communicate with my doctor and the  rest of my healthcare team and receive from and share with them my health  information that may be useful for my care and to facilitate requested patient  support services; <\/div>\n<div>&bull; To provide me  with informational and promotional materials relating to MannKind products and  services, and\/or my condition or treatment; and<\/div>\n<div>&bull; To improve,  develop, and evaluate products, services, materials, and programs related to my  condition or treatment.<\/div>\n<\/p><\/div>\n<p class=\"font20\"><em>Notification of Use and Signature <\/em><\/p>\n<p>In order for MannKind  to provide me with patient support services and\/or programs, MannKind needs to  collect and use my personal information, including <em>my <\/em>PHI. I understand that my PHI may include any information, in  electronic or physical form, in the possession of or derived from a health care  provider, health care plan, pharmacy, pharmaceutical company, laboratory and\/or  their contractor (&ldquo;Health Care Provider&rdquo;). This may include select information  from or about my medical history and general health, my health care plan  benefits, payment limits or restrictions covered by my health care plan policy,  and\/or my adherence to my treatment. \n\t<\/p>\n<p>I authorize my Health  Care Providers to disclose my PHI to  MannKind, and between themselves, as necessary, but only for the purposes  stated above in this Authorization.<\/p>\n<p class=\"font20\"><em>Expiration, Right to Obtain a Copy and Right to Cancel <\/em><\/p>\n<p>I understand that by  signing this form, I authorize my Health Care Providers, or others who might  hold my health information to only release it to MannKind employees, as well as  to its contractors and business partners performing the services set forth in  this Authorization. I also understand I am authorizing my personal information,  including my PHI, to be used  for the purposes described above.\n  <\/p>\n<p>I understand and  agree that by signing below, I am authorizing those who rely on this Authorization  to release my PHI for the earlier of five (5) years or until my participation  in the program ends through my cancellation, unless a shorter time period is  required by state law. \n  <\/p>\n<p>I  understand that I can obtain a copy of this Authorization or cancel this  Authorization at any time by calling MannKind at 1-844-622-7371, or by writing  to 30930 Russell Ranch Road, Suite 300, Westlake Village CA, 91362. If I cancel  my consent, I will no longer qualify for the services described. I also  understand that if a Health Care Provider is disclosing my PHI to MannKind on  an authorized on-going basis, my cancellation with MannKind will be effective  with respect to any such Health Care Providers as soon as they receive notice  of my cancellation.<\/p>\n<p class=\"font20\"><em>No Effect on Treatment<\/em><\/p>\n<p>I understand I do not  have to sign this Authorization and that my enrollment in any of the services  and\/or programs described above is entirely voluntary. I understand that  MannKind, as well as Health Care Providers, cannot require me, as a condition  of having access to medications, prescription drugs, treatment or other care,  to sign this Authorization. Federal Law (including HIPAA) requires a signed  authorization in order for MannKind to collect this information from my Health  Care Providers. I understand I cannot participate in the listed services and\/or  programs without signing this Authorization or an equivalent authorization with  my Health Care Providers. <\/p>\n<p class=\"font20\"><em>Information Received from Health Care Providers  <\/em><\/p>\n<p>I understand that  once my PHI has been disclosed to MannKind, federal privacy laws may no longer  apply and protect it from further disclosure. MannKind agrees, however, to  protect my PHI by only using and disclosing it as stated in the Authorization,  or as otherwise allowed or required by law. <\/p>\n<p class=\"font20\"><em>Authorization to Contact <\/em> <\/p>\n<p>I understand and  consent to MannKind contacting me using the contact information provided in  this form to enroll me in, operate, and administer the services described  above. I understand that the operation and administration of these services  and\/or programs may require that MannKind contact me by telephone or SMS\/text  and that my cell phone carrier&rsquo;s standard rates may apply for calls or text  messages to my cell phone.<\/p>\n<p class=\"font20\"><em>Electronic Signature<\/em> <\/p>\n<p>This Authorization  and related documents may be signed electronically. If signing electronically,  by typing your name in the signature section of this page, you agree that you  are signing this document. You understand that your electronic signature is  legally binding, just as if you signed a paper document, and you acknowledge  that you have read and understand this Patient Authorization Form.<\/p>\n<p>By signing below, I  am providing my consent and indicating my legal authorization for MannKind and  its contractors and business partners to use and share the personal information  I give only for the purposes described within this Authorization.<\/p>\n<\/div>\n<\/div>\n<div id=\"field_13_8\" class=\"form-group col gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox custom-control custom-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible col-12\"><label class='custom-control-label gfield_label gform-field-label gfield_label_before_complex'>By clicking here I certify that the information I have provided is true and correct and that I am not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare or Medicaid, or any private indemnity or HMO insurance plan that reimburses me for the entire cost of my prescription drugs. I also certify that I am not Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. I further certify that should I begin receiving prescription benefits from one of these types of programs at any time, I will no longer participate in this savings program.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_13_8'>\n<div class='gchoice gchoice_13_8_1'>\n\t\t\t\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Yes'  id='choice_13_8_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label class='custom-control-label' for='choice_13_8_1' id='label_13_8_1' class='gform-field-label gform-field-label--type-inline'>By clicking here I certify that the information I have provided is true and correct and that I am not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare or Medicaid, or any private indemnity or HMO insurance plan that reimburses me for the entire cost of my prescription drugs. I also certify that I am not Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. I further certify that should I begin receiving prescription benefits from one of these types of programs at any time, I will no longer participate in this savings program.<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"field_13_10\" class=\"form-group col gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox custom-control custom-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible col-12\"><label class='custom-control-label gfield_label gform-field-label gfield_label_before_complex'>I confirm that I am at least 18 years of age and have full legal authority to provide consent and authorization.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_13_10'>\n<div class='gchoice gchoice_13_10_1'>\n\t\t\t\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Confirm'  id='choice_13_10_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label class='custom-control-label' for='choice_13_10_1' id='label_13_10_1' class='gform-field-label gform-field-label--type-inline'>I confirm that I am at least 18 years of age and have full legal authority to provide consent and authorization.<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"field_13_11\" class=\"form-group col gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox custom-control custom-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible col-12\"><label class='custom-control-label gfield_label gform-field-label gfield_label_before_complex'>I have read and agree to the terms of this Patient Authorization and terms &amp; conditions of the Afrezza savings program.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox' id='input_13_11'>\n<div class='gchoice gchoice_13_11_1'>\n\t\t\t\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Yes'  id='choice_13_11_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label class='custom-control-label' for='choice_13_11_1' id='label_13_11_1' class='gform-field-label gform-field-label--type-inline'>I have read and agree to the terms of this Patient Authorization and <a href=\"#\" class=\"sg-popup-id-2852  terms\" data-popup-id=\"2852 \" data-toggle=\"modal\" data-target=\"#termsandconditions\">terms &amp; conditions<\/a> of the Afrezza savings program.<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"field_13_13\" class=\"form-group 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