Eligibility 8015- Patient

Please answer the highlighted question(s) in red.

Are you covered by commercial insurance coverage?*

YES

Do you reside in the United States or Puerto Rico?*

YES

Are you 18 years of age or older?*

YES

You are the one who will use this coupon eligible for reimbursement of prescriptions (in whole or in part) under any federal, state or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare programs?*

YES

I authorize my 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, including information related to my medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for DOPTELET ("Information") to (1) enroll me in and provide services under the Doptelet Connect^® patient support program (the "Program"); (2) obtain information on my insurance coverage; (3) coordinate prescription fulfillment as indicated by my 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 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 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 DOPTELET may receive payment from Sobi in exchange for disclosing my 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 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 I 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 1-866-547-0644 or by notifying Sobi in writing at Doptelet Connect, PO Box 5490, Louisville, KY 40255-5490. Cancellation of this Authorization will end further uses and disclosures of my Information and my participation in the Program but will not affect any uses or disclosure of my Information made by my 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.*

I AGREE

I DO NOT AGREE

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

I AGREE

I DO NOT AGREE

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 Doptelet. 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 1-833-368-2663, clicking the email link in a message received or by replying “Stop” by text to any text from Doptelet Copay Program. Doptelet Copay Program 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 5 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*

I AGREE

I DO NOT AGREE

Limitations apply. Valid only for those with private insurance. The program includes the copay card, payment card (if applicable) with a combined annual limit of $15,000. Patient is responsible for any costs once the dollar limit is reached during the program calendar year. Program is not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, or (iii) where the patients' insurance plan reimbursees the entire cost of the drug. The value of the program is exclusively for the benefit of patients and is not intended to be credited toward patient out-of-pocket obligations and maximums, including applicable co-payments, co-insurance and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the program. Valid only in the United States and Puerto Rico. This program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Sobi, Inc. reserves the right to rescind, revoke, or amend the program and discontinue support at any time without notice.

Please fill in all required information: