Authorization: I understand that my signature on this enrollment form constitutes my written authorization for MSC to receive and use the individually identifiable health information described above for the proper administration of Rx-tra Savings Program in accordance with applicable law. This authorization shall remain in effect for the duration of my enrollment in the Rx-tra Savings Program. I have the right to revoke this authorization in writing at any time by contacting Medical Security Card Company at 4911 E. Broadway Blvd, Suite 200, Tucson, AZ 85711 except to the extent that my medical information has already been used or disclosed in reliance on this authorization. However, because this information is essential to the administration of this program, my revocation of this authorization shall result in cancellation of my enrollment in the Rx-tra Savings Program. If you are signing on behalf of dependent family members, your signature verifies that you are the parent/legal guardian or the authorized representative of the individuals identified above.
Additional Health Savings Information: Pursuant to your enrollment in the Rx-tra Savings Program, MSC and Albertsons may also provide you with special information to enhance your health, such as drug price comparisons, and/or special savings opportunities (additional health savings information) through programs administered by MSC and/or Albertsons. Your signature below constitutes your written authorization for MSC and Albertsons to provide you with Additional Health Savings Information as described above. You may opt out of receiving future transmissions of Additional Health Savings Information by contacting MSC’s customer service department at 1-866-223-9675.