[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287372-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-287372-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","patient-authorization-form-patient-or-legal-representative-consent","Patient Authorization Form - Patient Or Legal Representative Consent","","Patient Authorization Form for enrolling in Madrigal Patient Support. The form captures required patient details, including contact and consent for text messaging, and includes patient or legal representative signature sections. It also collects prescriber and pharmacy information when available, to support coordination of coverage and assistance. Section 3 authorizes physicians, insurers, and specialty pharmacies to disclose health, demographic, and financial information to Madrigal for eligibility, enrollment, assistance, and product access administration.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/patient-authorization-form-patient-or-legal-representative-consent/287372/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/patient-authorization-form-patient-or-legal-representative-consent/287372.png","ImageObject",442,249,{"name":42,"@type":43},"Rhys","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does the form collect in the Patient Information section?","Question",{"text":63,"@type":64},"It collects first name, last name, date of birth, gender, address, phone/mobile options, permission to leave a detailed message, email permission, and (if any) legal representative details and relationship to the patient.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does the form authorize in Section 3 for access support?",{"text":68,"@type":64},"It authorizes healthcare providers, health insurers, and specialty pharmacies to disclose personal health and related information to Madrigal so Madrigal can provide access to the product, services, and programs described, including assistance and prescription coordination.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the authorization valid and how can it be revoked?",{"text":72,"@type":64},"It is valid for 18 months from the date support is last provided (or until local state law requires expiration), or until the authorization is revoked earlier. Revocation can be done by submitting a written notice to Madrigal Patient Support, and it will end eligibility for the described services.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},287372,1790030803,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":26},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Patient Authorization Form  \nBy completing this form, you are enrolling in Madrigal Patient Support. Through this program, eligible patients receive:  \n\n| Help identifying financial assistance options | Support getting started and throughout treatment |\n| --- | --- |\n\nEducation and tips from Nurse Navigators  \nHOW TO ENROLL  \nFAX ALL PAGES to 1-844-411-1177 or  \n[COMPLETE ONLINE scan QR code or visit ](COMPLETE ONLINE scan QR code or visit MadrigalEnrollmentPatient.com)[MadrigalEnrollmentPatient.com](COMPLETE ONLINE scan QR code or visit MadrigalEnrollmentPatient.com)  \nWe’re here to help.  \nCALL  \n1-877-219-7770  \nMonday – Friday, 8 AM – 8 PM ET VISIT  \n[MadrigalPatientSupport.com](MadrigalPatientSupport.com)  \n1. PATIENT INFORMATION AND SIGNATURE * Required information  \nFirst name*   Last name*   Date of birth (MM/DD/YYYY)*   Gender*  M  F  \nAddress*   Apt \\#    \nCity*   State*   ZIP*   Phone*    Mobile  Home  \nOK to leave detailed message? Yes  No  \nEmail*   OK to email? Yes  No  \nLegal representative (if any)   Relationship to patient   Representative phone    \nI have read and consent to the Patient Authorization for Access Support in Section 3.  \n\n| SIGN HERE | PATIENT OR LEGAL REPRESENTATIVE SIGNATURE* | DATE |  |\n| --- | --- | --- | --- |\n\nI have read and consent to the Patient Certifications in Section 4.  \n I have read the Text Messaging Consent in Section 4 and expressly consent to receive text messages from Madrigal.  \n\n| SIGN HERE | PATIENT OR LEGAL REPRESENTATIVE SIGNATURE* | DATE |  |\n| --- | --- | --- | --- |\n\nIf signed by  \nlegal representative  \nPrinted name  \n2. PRESCRIBER AND PHARMACY INFORMATION * Required information  \nPlease provide the following information if known. We will follow up if additional details are needed to support your access to therapy.  \nPrescriber name*   Phone   Address    \nCity   State   ZIP   Was your prescription sent to a pharmacy? Yes  No  \nIf yes, pharmacy name    \n1  US-PP-MDGL-00056-v3 5/25  \nPatient Authorization Form  \n3. PATIENT AUTHORIZATION FOR ACCESS SUPPORT  \nI authorize my physician(s) and their staff (together,“Healthcare Providers”), my health insurer, health plan or programs that provide me healthcare benefits (together,“Health Insurers”), and any specialty pharmacies (“Specialty Pharmacies”) that dispense my medication, to disclose my personal or other health information, which may include contact information, demographic information, financial information, and information related to my medical condition, treatments, and health insurance and benefits, to Madrigal Patient Support, and their respective partners, affiliates, subcontractors, and agents (together,“Madrigal”). I authorize Madrigal to receive, use, and share my information in order to provide me with access to the product, services, and programs described on this form, which may include the following:  \n• Working with my health insurance plan to understand or verify coverage for Madrigal products  \n• Enrolling in the Madrigal Patient Assistance Program (PAP)  \n• Determining my eligibility for and facilitating enrollment into financial assistance services if I’m eligible, including copay assistance  \n• Coordinating my prescription through a pharmacy. This includes contacting me to discuss my coverage, costs and eligibility for assistance and other program administration purposes  \n• Facilitating my access to Madrigal products through prior authorization for coverage and assistance with appeals of denied claims for coverage  \n• Ensuring quality and safety and improving our products and services  \nI understand that Madrigal may de-identify my information and use it in performing research, education, business analytics, marketing studies, or for other commercial purposes, including linkage with other de-identified information Madrigal receives from other sources. I understand that Madrigal may share my information, including identifiable health information, in order to de-identify it for these purposes and as ","cbCaiuiqc0yrRPRc","https://ap.wps.com/l/cbCaiuiqc0yrRPRc","pdf",226658,"English","# Patient Information and Signature\n# Prescriber and Pharmacy Information\n# Patient Authorization for Access Support","[{\"question\":\"What information does the form collect in the Patient Information section?\",\"answer\":\"It collects first name, last name, date of birth, gender, address, phone/mobile options, permission to leave a detailed message, email permission, and (if any) legal representative details and relationship to the patient.\"},{\"question\":\"What does the form authorize in Section 3 for access support?\",\"answer\":\"It authorizes healthcare providers, health insurers, and specialty pharmacies to disclose personal health and related information to Madrigal so Madrigal can provide access to the product, services, and programs described, including assistance and prescription coordination.\"},{\"question\":\"How long is the authorization valid and how can it be revoked?\",\"answer\":\"It is valid for 18 months from the date support is last provided (or until local state law requires expiration), or until the authorization is revoked earlier. Revocation can be done by submitting a written notice to Madrigal Patient Support, and it will end eligibility for the described services.\"}]","Patient Authorization Form - Patient Or Legal Representative Consent | PDF",1789632231]