Patient Authorization of Release and use of information

Telephone: 1.888.765.4747, Fax: 203.699.2000, 352 Knotter Drive, Cheshire, CT 06410

Patient Information

All information provided will be kept confidential.
* Required fields

Telephone number(s) of Patient (or Designated Representative, if applicable):

Designated Representative

Please fill out this section ONLY if the person signing this Authorization is not the patient.

Custodial Parent

Legal Guardian or Representative

Other (please explain)

Additional Permissions (optional)

I authorize Alexion to share my personal information with the following person(s):

Patient Authorization of release and use of information

By signing this Authorization, you agree to permit the Authorized Parties listed below to disclose Protected Health Information (PHI) about you to Alexion Pharmaceuticals, Inc. for the uses described more fully below.

THE AUTHORIZED PARTIES INCLUDE:

(1) Your primary care physician, evaluating and/or treating physician, and any specialist or other healthcare providers involved in your treatment (“Providers”); (2) the distributor, pharmacy, or home health agency that dispenses your medical therapy (“Distributors”); and (3) your health insurer, payor, or patient assistance program (“Payors”).

The PHI (“Information”) that may be disclosed includes medical reports, orders, prescriptions and records, histories, findings, prognoses, plans of care and discharge summaries, billing information, insurance claims, and utilization review reports.

The Authorized Parties may disclose this Information to Alexion Pharmaceuticals Corporation, including, but not limited to, its employees, sub-contractors, agents, and other representatives (together, “Alexion”), so that Alexion may use and disclose the Information for the following purposes:

1. Coordination of Care: Between you, the Providers, Distributors, or Payor for the coordination of your medical care.

2. Disease Management/Patient Education: To provide information, training, and case management services to you (or your representative), and any Providers, Payor, and Distributors.

3. Clinical Research/Treatment Protocols: To inform you (or your representative) of clinical research studies, treatment protocols, or disease-related surveys that may benefit you.

4. Reviewing Your Insurance Benefits/Plan and/or Funding Options: To review, verify, and to assist you in understanding the benefits provided by your Payor, to verify what services your benefits cover and help you obtain the services ordered by your Provider, to coordinate benefits, to determine appeal requirements, and to identify other sources of payment, if necessary.

5. Billing and Payment: To coordinate the preparation, filing, and processing of health insurance claims, the evaluation of coding (billing) issues, and assist with the resolution of any claims issues relating to your therapy.

6. Distribution of Hematologic Therapy: To coordinate the distribution of medical therapy to you.

7. Product Orders: To fulfill any product orders and answer any questions that you may provide to the Alexion call center, and otherwise to inform you about other services that may be of interest to you.

8. Government Agencies: To provide information as required or requested by representatives of government agencies, review boards, and others who watch over the safety of drugs (or operations) of pharmaceutical manufacturers.

9. Other Use of Information: To de-identify the information about you and to use this de-identified information in performing clinical research, patient and community education, clinical protocol development, marketing studies, or for other commercial purposes as determined by Alexion.

10. Contact: To contact you or your authorized representative (if designated above) by mail, e-mail, or telephone.

Once your Information has been disclosed to Alexion, federal privacy laws may no longer protect it from further disclosure. However, Alexion agrees to protect your Information by using and disclosing it only for the purposes described in this Authorization or as permitted by law.

You do not have to sign this Authorization. If you do not sign this Authorization, or choose to revoke it, your ability to obtain medical care and/or therapy, or your eligibility or enrollment for insurance benefits will not be affected. However, if you do not sign this Authorization, Alexion will not be able to provide the services described above.

This Authorization shall remain in effect until January 1, 2020 unless it is revoked (taken back) by you. You may revoke this Authorization at any time by sending a written letter which includes your name and address, to Alexion Pharmaceuticals, Inc. at the address or fax on the top of this form. You have the right to receive a copy of this Authorization upon request.

* Please acknowledge that you agree to the terms of the Patient Authorization of Release and Use of information set forth above by checking the box