About This Form

Cayston Access Program (CAP) is a patient support program designed to provide information about your CAYSTON® (aztreonam for inhalation solution) coverage, triages to Specialty Pharmacy for fulfillment, and other support offerings. CAP is an agent of Gilead Sciences, Inc. In order to provide financial assistance and information, Gilead Sciences will need to use your health information (called “Protected Health Information” or “PHI”), and to share it with your health plan and the pharmacy that will receive your doctor’s prescription. This authorization will allow your health care providers, and health insurers that maintain PHI about you to disclose your PHI to Gilead Sciences, Inc. and its contractors and agents so that the Support Center may provide financial assistance and information to you, or on your behalf.