* By clicking the "Add" button, I authorize Birdi to disclose my entire pharmacy record to the person named above (my "Representative"). This is at my request. I understand that (i) once my information is disclosed to my Representative it is no longer protected by federal privacy law and may be redisclosed by my Representative; (ii) my treatment, payment, enrollment or eligibility for benefits is not affected by whether I give this authorization, and (iii) I may cancel this authorization at any time by removing the Representative's access to my account in the Representatives section of Birdi.com, but this cancellation will not affect actions taken by Birdi based on this authorization before I cancel it. Unless I cancel it before then, this authorization expires three (3) years from today's date.
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