P: 1.888.847.4877 · F: 1.888.847.1797
P.O. Box 222138 · Charlotte, NC · 28222-2138
Do not include Patient Medical Records with this application.
© 2020 Sanofi US Services, Inc.
MAT-US-2020149-v1.0-09/2020
Please read the following carefully, then date and sign where indicated below.
Income Verification: Sanofi Patient Connection and its authorized third party agents will use my date of birth or social security number and/or additional
demographic information as needed to access my credit information and information derived from public and other sources to estimate my income in
conjunction with the eligibility determination process. As a soft credit inquiry, this option will not impact my credit score. Sanofi Patient Connection and its
authorized third party agents reserve the right to ask for additional documents and information at any time.
I state that the information and documents provided in connection with this application are complete and accurate. I agree to immediately inform
a Program representative and my Doctor/ Healthcare Provider if my income or insurance status changes during the course of my participation in
this Program.
HIPAA Consent: I authorize my healthcare providers and staff; my health insurer, health plan or programs that provide me health benefits (together, “Health
Insurers”) to disclose to, Sanofi US, its affiliated companies (i.e. Sanofi Pasteur U.S. and Genzyme, a Sanofi Company), Sanofi Cares North America, and
authorized third party agents involved in administration of this Program, (collectively “Program Sponsor”), health information about me, including information
related to my medical condition, treatment, health insurance coverage, claims, prescriptions and referral to and enrollment in this Program for purposes of
determining my participation in, and administering, the Program, which may include contacting me as well as my Doctor/Healthcare Provider, office/hospital
staff, insurer (public/private) or others. I understand a representative from Sanofi may contact me for follow-up on any adverse event I may report regarding a
Sanofi product. I authorize and consent to release of identifiable information about me including medical, financial and insurance records and information as
required for participation in the Program. I understand that identifiable information about me will be kept confidential and will not be further used or disclosed
except to administer the Program, or as required by law. I understand that information I authorize to be disclosed may be re-disclosed and is no longer
protected by Federal privacy regulations. I agree that this authorization is voluntary and that I may refuse to sign this authorization. Refusal to sign will not
affect my ability to obtain treatment but I will not be able to participate in this Program. Unless revoked, this authorization shall remain in effect throughout my
participation in the Program, including subsequent reapplication as required. I may withdraw this authorization at any time by written notification to my
Doctor/Healthcare Provider; however, withdrawal of authorization will terminate my participation in this Program and will not affect information already disclosed
under this Authorization.
I understand that it is my responsibility to follow-up with my prescriber or the Program to make sure that my re-orders, as appropriate, are requested in a timely
manner by my Provider so I do not run out of medication. I understand that Sanofi US and Sanofi Cares North America reserve the right at any time and
without notice to modify or change eligibility criteria or discontinue this Program.
Patient Authorization (REQUIRED)
By signing below, I acknowledge that I have read and agree to the Patient Authorization to
Use and Disclose Health Information above.
Patient/Representative Signature (REQUIRED)
4. PATIENT AUTHORIZATION (REQUIRED)
Please read the following carefully, then date and sign where indicated below.
I authorize the Program to contact me by mail, telephone, or e-mail, with information about the Program, disease state and products, promotions, services,
and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys. I further authorize the
Program to de-identify my health information and use it in performing research, including linkage with other de-identified information the Program receives
from other sources, education, business analytics, marketing studies, or for other commercial purposes. I understand that entities operating or administering
parts of the Program may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the
Services or to send the communications listed above (the “Communications”). I understand and agree that the Program may use my health information for
these purposes and may share my health information with my doctors, specialty pharmacies, and insurers. I understand that I may be contacted by the
Program in the event that I report an adverse event associated with a Sanofi product.
I understand that I do not have to opt in to receive the Communications, and that I can still receive patient assistance through the Program, as prescribed by
my physician. I may opt out of receiving Communications offered by the Program, at any time by notifying a Program representative by telephone at 1-800-
633-1610 or by mailing a letter to Sanofi US Customer Services, P.O. Box 5925 Mailstop 55A-220A5, Bridgewater, NJ 08807-5925. I also understand that the
Services may be revised, changed, or terminated at any time.
Patient Consent
By signing below, I acknowledge that I have read and agree to the Patient Consent above.
Patient/Representative Signature
