enroll in Acadia Connect^® today.

I, on behalf of myself or (if I am an authorized representative) my patient, hereby authorize and direct my or my patient’s healthcare providers (including physicians, prescribers, providers of long-term care, and pharmacies), health insurance companies, specialty pharmacies, and each of their respective representatives, employees, staff, and agents (collectively “Providers”), and any care partners or other individuals whom I list below (“Additional Care Partners”) to use Protected Health Information (“PHI”) about me or my patient (as applicable), and disclose it to each other and to Acadia Pharmaceuticals Inc. and its representatives and agents (collectively “Acadia”) to facilitate participation in the Services and to receive the Acadia News and Updates if I selected this option (collectively “Program”). I understand that this PHI may include, without limitation, contact information (name, address, phone number, email), and information about healthcare (medical condition, treatment and medications, care management, and health insurance). I understand that pharmacies may receive remuneration (payment) from Acadia for providing patient support services and disclosing associated PHI to Acadia pursuant to this authorization.

I also authorize Acadia to disclose to Providers and Additional Care Partners for Program purposes any information about me or (if I am an authorized representative) my patient, that Acadia may create or receive. I understand that information used or disclosed pursuant to this authorization may no longer be protected by certain state or federal privacy laws and may be subject to re-disclosure. I understand that I may refuse to sign this authorization, and my refusal will not affect the treatment I receive or my patient (as applicable) receives from Providers, nor will it affect my or my patient’s (as applicable) enrollment or eligibility for health insurance benefits to which I am or my patient (as applicable) is otherwise entitled. However, if I refuse to sign this authorization, I or my patient (as applicable) will not be able to participate in the Program, as the information used and disclosed as described in this form is necessary to facilitate participation in the Program. I also understand that I may cancel (revoke) this authorization at any time and request a signed copy of this authorization by calling 1-844-737-2223 or by mailing Acadia Connect^®, PO Box 15713, Pittsburgh, PA 15244; however, this cancellation will not apply to any information already used or disclosed in reliance on this authorization before notice of the cancellation is received. I understand that this authorization is valid for a period of 5 years or for a shorter period dictated by applicable state law.