What is the purpose of this authorization?

Federal and state privacy laws protect the use and disclosure of your health information. CVS Pharmacy® will not use your health information to administer the Pharmacy & Health ExtraBucks Rewards® Program ("the Program") unless you give your permission to do so through this authorization. This authorization describes the types of health information used by the Program as well as the different ways that the Program may use that information. Your information will be protected under state and federal laws and the CVS Pharmacy Privacy Policy as explained below. Additional information about the Program is available through the Pharmacy & Health ExtraBucks Rewards Program Rules or by calling 1-800-SHOP CVS.

Who has and who will use my information?

If you enroll in the Program, CVS Pharmacy and its affiliates (the legal entities that operate the pharmacies) will share your information with the ExtraCare® Program, which is the retail rewards program run by CVS Pharmacy. The ExtraCare Program team is responsible for administering the Program at CVS Pharmacy. The ExtraCare Program may utilize third party service providers to help administer the Program. Third party service providers are not permitted to use or further disclose your information for any other purposes. CVS Pharmacy will only use your information as permitted by its Privacy Policy. Further information about how CVS Pharmacy uses your information can be found at CVS.com®

What information will be used and disclosed?

If you give your permission through this form, you are allowing CVS Pharmacy to use and disclose the following information:

Your contact information, including your full name, address, phone number, and email address; and
Your activity information, which is (1) the type of activity you did to earn rewards, such as a prescription purchase, a flu or vaccine shot, signing up for the online prescription management tool, or other activities eligible for rewards in the Program; (2) how many times you did the activity; (3) when prescriptions are purchased, the unique identifier only of each prescription (this unique identifier does not disclose any information about the medication prescribed); and (4) whether the purchase was part of a government-funded program.

Pharmacy & Health ExtraBucks Rewards authorization

I authorize CVS Pharmacy and its affiliates to use and disclose my information:

to enroll me in the ExtraCare Pharmacy & Health Rewards™ program (the "Program"),
to administer the Program, including calculating and tracking my earned rewards,
to send me messages about the Program,
to send me marketing communications and offers, and
to send me information about programs that I may be interested in.

Note that if a new program to earn rewards is started under Pharmacy & Health ExtraBucks Rewards that will use or disclose different information than described here, I will be asked to opt in to the program before CVS Pharmacy would use or disclose such information.

I understand that:

My treatment, payment for treatment and eligibility for benefits at CVS Pharmacy does not depend on my signing this Authorization.
Since the Program is not subject to HIPAA, the federal law that regulates use of protected health information, the information held by the Program is no longer covered by the HIPAA Privacy Rule governing its use and disclosure, but I am still protected under federal and state consumer protection laws and CVS Pharmacy's Privacy Policy.
I have the right to cancel this Authorization at any time by calling 1-800-Shop CVS or at www.cvs.com/Rxrewards, but that my cancellation will not apply to any action that CVS Pharmacy has already taken based on this Authorization before then.
I am entitled to a copy of this Authorization.
Unless I cancel it before then, this Authorization will expire five (5) years from today.