MEDICAL INFORMATION REQUESTS

This form is intended for medical professionals only. If you are a healthcare professional and have a medical inquiry, complete this form and submit to Intercept Medical Information. If you need additional information, please contact us at medinfo@interceptpharma.com.
MDDOPharmDNPRPhPhDPARNOther HCP
PhoneEmail
In the event your request is for a publication reprint or the response to your medical information request necessitates the inclusion of a publication reprint, please select ONE of the following statements:
Please enclose any relevant reprints(s). I am aware that the value of the enclosed reprint(s) will be attributed to me and that Intercept will disclose a transfer of value associated with a reprint to the federal government in order to meet the requirements of the Patient Protection and Affordable Care Act ("ACA")†.Do not enclose any reprint(s) in the medical response. A list of citations in the response is sufficient.
†The ACA section entitled "Transparency Reports and Reporting of Physicians Ownership or Investment Interests," was enacted in 2010. This section of the ACA, also referred to as the Sunshine Act, mandates the reporting of the monetary value of clinical reprints provided to physicians. In addition, all transfers of value to US licensed physicians, including the value of reprints, will be published on the Centers for Medicare and Medicaid Services (CMS) Open Payments website annually. More information about Open Payments can be found at: https://www.cms.gov/openpayments/
In order to provide the information that you have requested, it is necessary for Intercept pharmaceuticals, Inc. to collect and process personal data about you (including, but not limited to your name and email address). This data will be processed based on Intercept’s legitimate interest in responding to your medical information request. The data will be provided to the appropriate Intercept departments, which may include transfer outside of Canada (e.g., to the USA), and will be retained in accordance with applicable data protection laws for a period necessary to comply with the purposes for which you have provided your data. Please note that while you are not obligated to provide your personal data, if you do not, we may not be able to respond to your request. If you have further questions, or need to request access to, rectification of, or erasure of personal data, or to object to processing, please contact us at privacyprotection@interceptpharma.com.
In order to provide the information that you have requested, it is necessary for Intercept Pharmaceuticals, Inc. to collect and process personal data about you (including, but not limited to your name and email address). This data will be processed based on Intercept’s legitimate interest in responding to your medical information request. The data will be provided to the appropriate Intercept departments, which may include transfer outside of the EU (e.g., to the USA), and will be retained in accordance with applicable data protection laws for a period necessary to comply with the purposes for which you have provided your data. Intercept is certified to the EU-US and Swiss-US Privacy Shield with respect to personal data collected by entities located in the European Economic Area and Switzerland and transferred to Intercept in the United States. Please note that while you are not obliged to provide your personal data, if you do not, we may not be able to respond to your request. If you have further questions, or need to request access to, rectification of, or erasure of personal data, or to object to processing, please contact us at privacyprotection@interceptpharma.com. You can also lodge a complaint regarding the processing of your personal data with the relevant supervisory authority.
In order to provide the information that you have requested, it is necessary for Intercept pharmaceuticals, Inc. to collect and process personal data about you (including, but not limited to your name and email address). This data will be processed based on Intercept’s legitimate interest in responding to your medical information request. The data will be provided to the appropriate Intercept departments, which may include transfer outside of Israel (e.g., to the USA), and will be retained in accordance with applicable data protection laws for a period necessary to comply with the purposes for which you have provided your data. Please note that while you are not obligated to provide your personal data, if you do not, we may not be able to respond to your request. If you have further questions, or need to request access to, rectification of, or erasure of personal data, or to object to processing, please contact us at privacyprotection@interceptpharma.com.
I understand that checking this box constitutes my legal signature, that I am a healthcare professional, and I acknowledge that my medical information request has been unsolicited.


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