By registering online with Touchpoints^SM Recovery Support, I authorize Alkermes, Inc., Group DCA and Alliance to use and disclose to each other my medical and other information set forth in this registration, including information about my treatment with VIVITROL (taken together, “Information”) for the purpose of providing me with educational and therapy support services (that may include product information materials and treatment reminders) by mail, e-mail and/or telephone. I understand that the parties to which I have authorized disclosure in this authorization may not be subject to applicable federal and state privacy laws and that my Information could be subject to redisclosure. I understand that signing this authorization is voluntary and if I do not sign this authorization it will not affect my ability to obtain treatment from my prescribing physician or obtain insurance or insurance benefits. I understand, however, that if I do not sign this authorization, I will not be eligible to receive the educational and support services described above. I understand I have the right to receive a copy of this authorization after I sign. I understand that I may see a copy of the Protected Health Information described in this authorization if I request to do so. I may withdraw this authorization at any time by mailing or faxing a written request to Touchpoints^SM Recovery Support; 4511 Singer Court; Suite 210; Chantilly, VA 20151 or by calling 1-800-848-4876. Withdrawal of this authorization will end further uses and disclosures of my Information by the parties identified in this authorization except to the extent those uses and disclosures have been made in reliance upon this authorization and as permitted by applicable law. This authorization expires five years from the date indicated below unless I withdraw it earlier.