Enroll Here

Enrollment Form

TO BE COMPLETED BY THE PATIENT/CAREGIVER

STEP 1: Patient Information

Patient First Name

Patient Last Name

Patient Address

City

State *

Zip

Date of Birth

Sex

Male

Female

Other/Undisclosed

Phone #

Preferred Method of Contact *

Consented by Other

Required if patient is under 18 years of age.

Parent/Legal Guardian First Name *

Parent/Legal Guardian Last Name *

Relationship to Patient

Parent/Legal Guardian Phone #

I authorize Ipsen to share my personal health information (PHI) and to discuss my case history and treatment plan, including my PHI, with the individual(s) named below for the sole purpose of facilitating my treatment.

First Name *

Last Name *

Relationship to Patient

Phone #

First Name *

Last Name *

Relationship to Patient

Phone #

First Name *

Last Name *

Relationship to Patient

Phone #

Next Step

STEP 2: Insurance Information

Is Patient Insured? *

Yes

Primary Insurance Co.

Insurance Co. Phone #

Subscriber Policy ID #

Policy/Employer/Group #

Policyholder same as patient?

Yes

Policyholder First Name *

Policyholder Last Name *

Policyholder Date of Birth

Does patient have secondary insurance? *

Yes

Secondary Insurance Co.

Insurance Co. Phone #

Subscriber Policy ID #

Policy/Employer/Group #

IPSEN CARES Copay Program

Eligible patients using commercial insurance can save on out-of-pocket Ipsen medication costs. Please see Patient Eligibility & Terms and Conditions.

I attest that I am not enrolled in any health insurance plan from any state or federally funded programs (including, but not limited to, Medicare or Medicaid, VA, DOD, or TRICARE) and agree to the Terms and Conditions of the Copay Program.

Yes

I would like IPSEN CARES to check my eligibility for, and enroll me into, the IPSEN CARES Copay Program if the results of this benefit verification determine that I have commercial or private health insurance.

Next Step

STEP 3: Patient Authorization

STEP 4: Consent for Use of Genetic Information

NOTE: If you are providing this consent on behalf of the patient, your signature will certify that you are authorized to agree as indicated on the patient’s behalf and that references to “you” shall mean “the patient.”

Your genetic information is protected by laws in your state. That means you have choices about whether to take a genetic test, whether and whom you allow to access genetic information about you, whether you would like your genetic information to be retained for specific purposes, and whether and how you allow the genetic information to be disclosed.

If you wish to participate in IPSEN CARES, please read this consent form carefully.

You may refuse to provide consent to allow us to access or disclose all or some of your genetic information, but your refusal will mean that you cannot participate in IPSEN CARES. Refusal to sign will not affect your eligibility to obtain medical treatment, your ability to seek payment for this treatment, or affect your insurance enrollment or eligibility for insurance coverage.

If you have any questions about the program or wish to withdraw your consent, please call 844-484-1234.

If we make any substantive changes to the program that impacts the disclosures included in this form, we will provide you with a new consent form and, if required by law, obtain a new consent from you.

Genetic Information

Ipsen will access and retain the following categories of genetic information about you (collectively, your “Personal Genetic Information”): genetic markers.

How We Will Use Your Genetic Information

To the extent necessary to assist you in securing insurance coverage and coordination with the specialty pharmacy for access to the product, the information may be disclosed to your provider of health insurance.

Purposes for Which We Access, Use, and Retain Your Genetic Information

Ipsen may receive the genetic information described above for the following purposes:

To enroll you in and provide services under the IPSEN CARES
To facilitate your participation in other patient programs as you have requested or may request
To comply with legal and regulatory requirements

Disclosure of Your Genetic Information

As noted, Ipsen may disclose your Personal Genetic Information to your provider of health insurance to the extent necessary to assist you in securing insurance coverage for product and to the specialty pharmacy for coordination for your access to the product. Ipsen may also disclose this information to authorized employees and contractors for the purposes identified above. Ipsen may also disclose your genetic information to other third parties, including government agencies, to the extent permissible under applicable state laws.

Ipsen takes reasonable security measures to protect your genetic information from accidental loss and from unauthorized access, use, acquisition, alteration, or disclosure when the genetic information is in transit and at rest. However, once your genetic information has been disclosed by a third party, it may no longer be protected by federal privacy laws and the third party may be permitted to re-disclose it. Therefore, we cannot guarantee that your genetic information will remain confidential after being disclosed to third parties and government agencies. If your genetic information becomes known to others, it may negatively affect your insurability, employability, and social discrimination.

How We Will Store Your Genetic Information

While you are part of IPSEN CARES, Ipsen will retain all genetic information gathered about you in our database. This information will only be accessible to Ipsen staff who need to access it in order to administer, support, or evaluate the program. If you choose to leave, or become ineligible for, the program, the collected genetic information will be archived and not undergo further analysis except to meet our obligations to maintain records of the services offered by our program, to meet legal requirements, and to protect ourselves against legal claims linked to the program. We will retain this information for as long as necessary to meet these objectives and for as long as permitted or required by applicable law.

By signing this form, you direct us to retain your genetic information indefinitely upon completion of the program, subject to the above retention period and your right to withdraw this consent..

Your Rights With Respect to the Genetic Information We Collect About You

You have the right to receive a copy of this consent form signed by you and to access your genetic information. To exercise your rights described under this section, please call 844-484-1234.

We collect personal information to fulfill your request. Please see our Privacy Policy and our State Supplemental Privacy Policy for more information.