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TAKEDA PATIENT SUPPORT ENROLLMENT FORM

Takeda Patient Support is a program that can help eligible patients prescribed a
Takeda Hematology product with education and resources to help access their
therapy and support them throughout their treatment journey.

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PLEASE VERIFY YOUR TAKEDA HEMATOLOGY PRODUCT.*

Select ADVATE® [Antihemophilic Factor (Recombinant)] ADYNOVATE® [Antihemophilic
Factor (Recombinant), PEGylated] ADZYNMA (ADAMTS13, recombinant-krhn) FEIBA®
(anti-inhibitor coagulant complex) HEMOFIL M® [Antihemophilic Factor (Human),
Method M, Monoclonal Purified] RECOMBINATE® [Antihemophilic Factor
(Recombinant)] RIXUBIS® [Coagulation Factor IX (Recombinant)] VONVENDI® [von
Willebrand factor (Recombinant)]
Select Product


PATIENT INFORMATION

First Name*
Enter First Name
Last Name*
Enter Last Name
Date of Birth*
Enter Date of Birth
Gender* Select MALE FEMALE
Select Gender
Takeda and its partners recognize that patients may not identify as male or
female. However, many insurance companies still require that one of these two
fields be used for each of their members. Please indicate the gender on file
with the patient’s insurance company.
Address*
Enter Address
City*
Enter City
State* Select
Select State
ZIP*
Enter ZIP
Email*
Enter Email
Primary Phone*
Enter Primary Phone
Phone Type* Select HOME MOBILE
Select Phone Type


DOES THIS PATIENT HAVE A LEGAL REPRESENTATIVE?*

Yes
No
Make a selection
Legal Representative First Name*
Enter Legal Representative First Name
Legal Representative Last Name*
Enter Legal Representative Last Name
Relationship to Patient* Select SPOUSE DOMESTIC PARTNER SIGNIFICANT OTHER
SIBLING CHILD PARENT GRANDPARENT GRANDCHILD AUNT/UNCLE NIECE/NEPHEW FRIEND OTHER
Select Relationship to Patient
Legal Representative Email*
Enter Legal Representative Email
Legal Representative Phone*
Enter Legal Representative Phone
CONTINUE



TAKEDA PATIENT SUPPORT ENROLLMENT FORM

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INSURANCE

Please check this box if the patient does not have insurance.


PRIMARY INSURANCE

Primary Insurance*
Enter Primary Insurance
Policyholder Name*
Enter Policyholder Name
Policy ID #*
Enter Policy ID #
Group #*
Enter Group #


SECONDARY INSURANCE

Secondary Insurance
Policyholder Name
Policy ID #
Group #


PHARMACY PLAN

Pharmacy Plan Name
Policy ID #
Policy Group #
Rx BIN #
Rx PCN #

BACK CONTINUE



TAKEDA PATIENT SUPPORT ENROLLMENT FORM

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PRESCRIBER INFORMATION

Prescriber First Name*
Enter Prescriber First Name
Prescriber Last Name*
Enter Prescriber Last Name
Facility Name
Office Contact
Facility Tax ID
Facility NPI
Facility Address
City
State Select Select
ZIP
Email
Phone
Fax

BACK CONTINUE



TAKEDA PATIENT SUPPORT ENROLLMENT FORM

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ACKNOWLEDGE

PLEASE REVIEW THE FOLLOWING AND ACKNOWLEDGE TO PROCEED.

PATIENT HIPAA AUTHORIZATION

By signing the Patient Authorization section of this Form, I authorize my
physician, health insurance, and pharmacy providers (including any specialty
pharmacy that receives my prescription) to disclose my protected health
information, including, but not limited to, information relating to my medical
condition, treatment, care management, and health insurance, as well as all
information provided on this form (“Protected Health Information”), to Takeda
Pharmaceuticals U.S.A., Inc. and its present or future affiliates, including the
affiliates and service providers that work on Takeda’s behalf in connection with
the Takeda Patient Support Program (the “Companies”). The Companies will use my
Protected Health Information for the purpose of facilitating the provision of
the Takeda Patient Support Program products, supplies, or services as selected
by me or my physician and may include (but not be limited to) verification of
insurance benefits and drug coverage, prior authorization support, financial
assistance with co-pays, patient assistance programs, and other related
programs. Specifically, I authorize the Companies to 1) receive, use, and
disclose my Protected Health Information in order to enroll me in the Takeda
Patient Support Program and contact me, and/or the person legally authorized to
sign on my behalf, about the Takeda Patient Support Program; 2) provide me,
and/or the person legally authorized to sign on my behalf, with educational
materials, information, and services related to the Takeda Patient Support
Program; 3) verify, investigate, and provide information about my coverage,
including but not limited to communicating with my insurer, specialty
pharmacies, and others involved in processing my pharmacy claims to verify my
coverage; 4) coordinate prescription fulfillment; and 5) use my information to
conduct internal analyses.

I understand that employees of the Companies only use my Protected Health
Information for the purposes described herein, to administer the Takeda Patient
Support Program or as otherwise required or allowed under the law, unless
information that specifically identifies me is removed. Further, I understand
that my healthcare provider may receive financial remuneration from Takeda
Pharmaceuticals U.S.A. for marketing services. I understand that Protected
Health Information disclosed under this Authorization may no longer be protected
by federal privacy law. I understand that I am entitled to a copy of this
Authorization. I understand that I may revoke this Authorization and that
instructions for doing so are contained in Takeda’s Website Privacy Notice
available at www.takeda.com/privacy-notice/ or I may revoke this Authorization
at any time by sending written notice of revocation to the Takeda Patient
Support Program, PO Box 2355, Morristown, NJ 07962. I understand that such
revocation will not apply to any information already used or disclosed through
this Authorization. This Authorization will expire at the earliest of what is
required by state law, and never in any case longer than 5 years. I also
understand that if I do not sign this Authorization, I will not be able to
receive the Takeda Patient Support Program products, supplies, or services.

Patient HIPAA Authorization: I have read, understand, and agree to the release
of my protected health information as described above.*
Required
Who is signing this consent?*
Patient
Legal Representative
Make a selection

SIGNATURE*

Type your signature.
Signature required
Date of Certification

TAKEDA PATIENT SUPPORT SERVICES ENROLLMENT

By signing below, I am electing to enroll in Takeda Patient Support for
Hematology Services (“Services”) and direct all disclosures of my Information in
connection with such Services (which may include, but are not limited to,
verification of insurance benefits and drug coverage, prior authorization
support, financial assistance with co-pays, patient assistance programs,
alternate funding sources, other related programs, communication with me or my
prescribing physician by mail, email, or telephone about my medical condition,
treatment, care management, product information, and health insurance).

Takeda Patient Support Services Enrollment: I agree to be enrolled in product
support services through Takeda Patient Support.*
Required
Who is signing this consent?*
Patient
Legal Representative
Make a selection

SIGNATURE*

Type your signature.
Signature required
Date of Certification

MARKETING COMMUNICATIONS OPTIONAL

Consent for Marketing Information: By checking the box, I authorize the use of
my Information for Takeda marketing activities and consent to receiving
marketing and promotional communications from Takeda. I hereby give consent to
Takeda, its affiliates, and their agents and representatives to send
communications and information to me via the contact information I have provided
above. I understand that this consent will be in effect until I cancel such
authorization.

TEXT MESSAGING AGREEMENT TERMS & CONDITIONS OPTIONAL

By agreeing to these Takeda Patient Support Program (the “Program”) text message
terms and conditions, you agree to receive text messages on your mobile device
subject to the Terms & Conditions described below. You also consent to receive
autodialed and/or pre-recorded calls and/or text messages from or on behalf of
the Program at the telephone number provided above. You understand that this
consent is not a condition of purchase or use of the Program or of any Takeda
product or service. You can unsubscribe from receiving text messages by texting
STOP. You will remain enrolled in Takeda Patient Support. For questions about
this Program, text HELP or contact the customer support center at 888-229-8379.

Participants will receive an average of 5 text messages each month while
enrolled in the Program. Such messages may be nonmarketing messages related to
the Patient Support Program.

There is no fee payable to Takeda to receive text messages; however, your
carrier’s message and data rates may apply.

You represent that you are the account holder for the mobile telephone number(s)
that you provide to opt into the Program. You are responsible for notifying
Takeda immediately if you change your mobile telephone number. You may notify
Takeda of a number change by calling 888-229-8379.

Data obtained from you in connection with your registration for, and use of,
this SMS service may include your phone number and/or email address, related
carrier information, and elements of pharmacy claim information and will be used
to administer this Program and to provide Program benefits such as information
about your prescription, refill reminders, as well as Program updates and
alerts.

Takeda will not be liable for any delays in the receipt of any SMS messages as
delivery is subject to effective transmission from your network operator.

This Program is valid with most major U.S. carriers, including Verizon Wireless,
Sprint, Nextel, Boost Mobile, T-Mobile®, AT&T, Alltel, ACS Wireless, Bluegrass
Cellular, Carolina West Wireless, CellCom, Cellular One of East Central Illinois
(ECIT), Cincinnati Bell, Cricket, C-Spire Wireless, Duet IP (aka
Max/Benton/Albany), Element Mobile, Epic Touch, GCI Communications, Golden
State, Hawkeye (Chat Mobility), Hawkeye (NW Missouri Cellular), Illinois Valley
Cellular (IVC), Inland Cellular, iWireless, Keystone Wireless (Immis/PC
Management), MetroPCS, MobiPCS, Mosaic, MTPCS/Cellular One (Cellone Nation),
Nex-Tech Wireless, nTelos, Panhandle Telecommunications, Pioneer, Plateau, Revol
Wireless, Rina-Custer, Rina-All West, Rina-Cambridge Telecom Coop, Rina-Eagle
Valley Comm, Rina-Farmers Mutual Telephone Co, Rina-Nucla Nutria Telephone Co,
Rina-Silver Star, Rina-South Central Comm, Rina-Syringa, Rina-UBET, Rina-Manti,
Simmetry, South Canaan/CellularOne of NEPA, Thumb Cellular, Union Wireless,
United Wireless, U.S. Cellular, Viaero Wireless, Virgin Mobile, and West Central
Wireless (includes Five Start Wireless). By agreeing to these Takeda Patient
Support Program (the “Program”) text message terms and conditions, you agree to
receive text messages on your mobile device subject to the Terms & Conditions
described below. You also consent to receive autodialed and/or pre-recorded
calls and/or text messages from or on behalf of the Program at the telephone
number provided above. You understand that this consent is not a condition of
purchase or use of the Program or of any Takeda product or service. You can
unsubscribe from receiving text messages by texting STOP. You will remain
enrolled in the Takeda Patient Support Program. For questions about this
Program, text HELP or contact the customer support center at 888-229-8379.

Participants will receive an average of 5 text messages each month while
enrolled in the Program. Such messages may be nonmarketing messages related to
the Patient Support Program.

Text Communication Enrollment: I have read, understand, and agree to opt-in for
text communications as described above.
Who is signing this consent?*
Patient
Legal Representative
Make a selection

SIGNATURE*

Type your signature.
Signature required
Date of Certification

BACK CONTINUE



TAKEDA PATIENT SUPPORT ENROLLMENT FORM

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CO-PAY ELIGIBILITY

Is the patient 18 years of age or older?*
Yes
No
Make a selection
Is the patient a resident of the United States or its Territories?*
Yes
No
Make a selection
Does the patient have commercial (also known as private) insurance? This
includes insurance from an employer and non-government funded insurance
purchased from a health insurance marketplace.*
Yes
No
Make a selection
Is the patient’s prescription covered in part or full under any state or
federally funded programs such as Medicare (including Medicare Part D and
Medicare Advantage), Medicaid, Medigap, VA, DoD, State Pharmacy Assistance,
TRICARE, etc?*
Yes
No
Make a selection
Is the patient currently receiving assistance from any other charitable
organization for any of their out-of-pocket costs that are covered by the Takeda
Patient Support for Hematology Co-pay program?*
Yes
No
Make a selection

CO-PAY ACKNOWLEDGMENT (TERMS AND CONDITIONS)

Takeda’s Co-pay Assistance Program (“the Program”) provides financial support
for commercially insured patients who qualify for the Program. Participation in
the Program and provision of financial support is subject to all Program terms
and conditions, including but not limited to eligibility requirements, the
Program maximum benefit per claim and the annual calendar year Program maximum
(“Annual Program Maximum”). The Annual Program Maximum for your prescribed
Takeda product can be found by visiting:
https://www.takedapatientsupport.com/hematology.

By enrolling in the Program, you agree that the Program is intended solely for
the benefit of you—not health plans and/or their partners. Further, you agree to
comply with all applicable requirements of your health plan. The Program cannot
be used if the patient is a beneficiary of, or any part of the prescription is
covered by: 1) any federal, state, or government-funded healthcare program
(Medicare, Medicare Advantage, Medicaid, TRICARE, etc.), including a state
pharmaceutical assistance program (the Federal Employees Health Benefit (FEHB)
Program is not a government-funded healthcare program for the purpose of this
offer), 2) the Medicare Prescription Drug Program (Part D), or if the patient is
currently in the coverage gap, or 3) insurance that is paying the entire cost of
the prescription. No claim for reimbursement of the out-of-pocket expense amount
covered by the Program shall be submitted to any third-party payer, whether
public or private.

Some health plans have established programs referred to as ‘co-pay maximizer’
programs. A co-pay maximizer program is one in which the amount of a patient’s
out-of-pocket costs is adjusted to reflect the availability of support offered
by a manufacturer’s co-pay assistance program. If you are enrolled in a co-pay
maximizer program, your Annual Program Maximum may vary over time to ensure the
program funds are used for your benefit (for the benefit of the patient). Takeda
also reserves the right to reduce or eliminate the co-pay assistance available
to patients enrolled in an insurance plan that utilizes a co-pay maximizer
program.

If you learn your health plan has implemented a co-pay maximizer program, you
agree to notify the Program immediately by calling 1-888-229-8379. It may be
possible that you are unaware whether you are subject to a co-pay maximizer
program when you enroll or re-enroll in the Program. Takeda will monitor program
utilization data and reserves the right to discontinue assistance under the
Program at any time if Takeda determines that you are subject to a co-pay
maximizer, or similar program.

The Program only applies in the United States, including Puerto Rico and other
U.S. territories, and does not apply where prohibited by law, taxed, or
restricted. This does not constitute health insurance. Void where use is
prohibited by your insurance provider. If your insurance situation changes you
must notify the Program immediately at 1-888-229-8379. Coverage of certain
administration charges will not apply for patients residing in states where it
is prohibited by law.

This Program offer is not transferable and is limited to one offer per person
and may not be combined with any other coupon, discount, prescription savings
card, rebate, free trial, patient assistance, co-pay maximizer, alternative
funding program, copay accumulator, or other offer, including those from third
parties and companies that help insurers or health plan manage costs. Not valid
if reproduced.

By utilizing the Program, you hereby accept and agree to abide by these terms
and conditions. Any individual or entity who enrolls or assists in the
enrollment of a patient in the Program represents that the patient meets the
eligibility criteria and other requirements described herein. You must meet the
Program eligibility requirements every time you use the Program. Takeda reserves
the right to rescind, revoke, or amend the Program at any time without notice,
and other terms and conditions may apply.

Who is signing this consent?*
Patient
Legal Representative
Make a selection

SIGNATURE*

Type your signature.
Signature required
Date of Certification

BACK CONTINUE



TAKEDA PATIENT SUPPORT ENROLLMENT FORM

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REVIEW

Please review the information below and confirm accuracy before submitting.

PATIENT INFORMATION

First Name
Last Name
Date of Birth
Gender
Address
City
State
ZIP
Email
Primary Phone
Phone Type Mobile
SMS Consent

LEGAL REPRESENTATIVE INFORMATION

None
First Name
Last Name
Relationship
Email
Phone

INSURANCE

None
Primary Insurance
Policyholder Name
Policy ID #
Group #

SECONDARY INSURANCE

None
Secondary Insurance
Policyholder Name
Policy ID #
Group #

PHARMACY PLAN

None
Pharmacy Plan Name
Policy ID #
Policy Group #
Rx BIN #
Rx PCN #

PRESCRIBER INFORMATION

First Name
Last Name
Facility Name
Office Contact
Tax ID #
NPI #
Address
City
State
ZIP
Email
Phone
Fax
PRINT PAGE

BACK SUBMIT





YOUR APPLICATION MAY NOT BE ELIGIBLE FOR OUR CO-PAY PROGRAM

You have enrolled into Takeda Patient Support for Hematology. While your
application may not be eligible for the Co-pay Program, there are additional
support services such as product access, educational resources and financial
assistance that may be available to you. If you have questions, please contact
Takeda Patient Support for Hematology at 1-888-229-8379.


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US-XMP-2770v4.0 05/24






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