Synagis Copay Assistance Program^†

*Is the patient covered by commercial insurance coverage?

*Does the patient reside in the United States or Puerto Rico?

*Will any of the patients prescription claims be reimbursed, in whole or in part, by any state or federal government program, including, but not limited to Medicaid, Medicare, Medigap Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state patient or pharmaceutical assistance program?

Patient Privacy Authorization
*I authorize my child's healthcare providers and staff, pharmacies, and health insurers to use and to disclose to Sobi, Inc., and its affiliates, business partners, vendors, and other agents (collectively, “Sobi”) health information about my child, including information related to my child's medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for SYNAGIS (“Information”) to (1) enroll my child in and provide services under the SYNAGIS CONNECT™ patient support program (the “Program”); (2) obtain information on my child's insurance coverage; (3) coordinate prescription fulfillment as indicated by my child's physician; (4) provide me with adherence reminders and support; and (5) contact me to conduct market research and to arrange for my receipt of educational, promotional, and/or marketing materials about Sobi support programs or Sobi products. Once my child's Information has been disclosed to Sobi, I understand that federal privacy laws may no longer protect it from further disclosure. However, I also understand that Sobi will protect my child's Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law.
I understand and agree that the pharmacy that dispenses SYNAGIS may receive payment from Sobi in exchange for disclosing my child's Information to Sobi and providing Program services.
I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my child's ability to obtain medical treatment from healthcare providers, eligibility for health insurance benefits, or access to Sobi medications. However, if I do not sign this Authorization, I understand my child will not be able to participate in the Program.
I understand that this Authorization expires ten years from the date signed below, or as otherwise required by state or local law, unless and until I cancel (take back) this Authorization before then. I may change my mind and cancel this Authorization at any time by calling 1-833-SYNAGIS (1-833-796-2447) or by notifying Sobi in writing at SYNAGIS CONNECT, PO BOX 1989, COLUMBUS, OH 43216. Cancellation of this Authorization will end further uses and disclosures of my child's Information and my child's participation in the Program but will not affect any uses or disclosure of my child's Information made by my child's health care providers and staff, pharmacies, and health insurers based on this Authorization before receipt of the cancellation. I understand I may request a signed copy of this Authorization.

*By signing, I agree to be contacted by email at the address I have provided or to receive autodialed phone or text messages ("texts") at the mobile phone number I have provided for the purpose of helping me/the patient stay on therapy, which may promote or advertise Synagis. I certify that the number I am providing belongs to me and not a family member or third party. I understand that I may opt out of individual communications of the program entirely by calling 833-SYNAGIS, clicking the email link in a message received or by replying "Stop" by text to any text from Synagis Connect. Synagis Connect will not sell or rent this information and will use it only in accordance with this authorization and consent. Consent to being contacted by email, phone or text messages is not a condition of participation in the programs or the purchase of any products or services. I understand that my cellular service carrier's data and text messaging rates may apply. This authorization is valid for 2 years from the date the form is signed. If I am providing this consent on behalf of another person, I certify that I am authorized to agree to every element of this consent on behalf of such other person, and I agree that I will be liable and will hold SOBI Inc harmless in the event that such other person alleges that they did not give consent

*By clicking the submit button, I am agreeing that all information contained in this enrollment is complete and accurate

By clicking the submit button, I am agreeing that I have read, understood and will comply with the terms and conditions of the program and that patient currently meets all eligibility criteria.