SMD US 003651 Patient Authorization Form

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IPSEN CARES PATIENT AUTHORIZATION FORM

PLEASE BE SURE TO REVIEW ORIGINAL IPSEN CARES ENROLLMENT FORM

I authorize my healthcare providers (including those pharmacies that may receive my prescription for Somatuline® Depot), to disclose personal health information (“PHI”) about me, including health information relating to my medical condition, prescription, and insurance coverage, to Ipsen Biopharmaceuticals, Inc., its affiliates, and its agents that have been hired to administer the Ipsen Coverage, Access, Reimbursement & Education Support (IPSEN CARES) program on its behalf (collectively, “Ipsen”) in order for Ipsen to (1) enroll me in IPSEN CARES; (2) establish my benefit eligibility and potential out-of-pocket costs for Somatuline® Depot; (3) communicate with my healthcare providers and health plans about my treatment plan; (4) provide support services including patient education and financial assistance for Somatuline® Depot; (5) help get Somatuline® Depot shipped to me or my healthcare providers; (6) evaluatemy eligibility for home health administration if requested by my physician; and (7) facilitate my participation in Somatuline® Depot patient programs that I have elected to receive information about, as indicated below. I agree that, using the contact information I provide, Ipsen may contact me for reasons related to the IPSEN CARES program and support services and may leave messages for me that may disclose that I am on Somatuline® Depot therapy. I consent tobeing contacted by an IPSEN CARES program representative in order for the program to obtainfurther information or clarification regarding any adverse event I may experience.

I understand that once my PHI has been disclosed to Ipsen, it is no longer protected by federalprivacy laws and Ipsen may re-disclose it; however, Ipsen has agreed to protect my PHI by using and disclosing it only for the purposes described above or as required by law. I understand that my healthcare providers may receive remuneration from Ipsen in exchange for my PHI and/or for any therapy support services provided to me.

I can withdraw this authorization by calling IPSEN CARES at 1-866-435-5677 or mailing a letterrequesting such revocation to IPSEN CARES, 11800 Weston Parkway, Cary, NC 27513, but it willnot change any actions taken before I withdraw authorization. Withdrawal of authorization will end further uses and disclosures of PHI by the parties identified in this form except to the extent those uses and disclosures have been made in reliance upon my authorization. I understandthat I may refuse to sign this form and, if I do so, I will not be able to participate in IPSEN CARES programs, but it will not affect my eligibility to obtain medical treatment, my ability to seek payment for this treatment, or affect my insurance enrollment or eligibility for insurance coverage. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. I understand that I willreceive a copy of the signed authorization.

Text Adherence Program

I agree to be contacted by autodialed text messages (“texts”) at the mobile phone number I have provided below for the purpose of helping me/the patient stay on therapy, which may promote oradvertise the Ipsen products included in the therapy plan. 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 at any time by calling 866-435-5677 or replying “STOP” by text to any text from Ipsen. Ipsen will not sell or rent this information and will use it only in accordance with this authorization and consent. Consent to being contacted by text messages is not a condition of participation in the IPSEN CARES programs or the purchase of any products or services. I understand that my cellular service carrier’s data and text messaging rates may apply. Privacy policy at www.ipsencares.com. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. 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 Ipsen harmless in the event that such other person alleges that they did not give consent.

Marketing Information

To the extent that I have opted in under step one of this form, I would like to receive information from Ipsen via mail, email, phone or SMS/text message, all of which may include marketing content, advertisements, disease state awareness materials and educational material about SOMATULINE® DEPOT, and programs that support patients. These text messages and voice calls may be made via the use of automatic telephone dialing systems. I certify that the number I am providing belongs to me and not to a family member or other third party. I understand that I do not have to sign this section of the form in order to participate in the IPSEN CARES program and that I may revoke this authorization to receive additional product information at any time. By signing below, I agree that Ipsen and its agents may use and disclose my personal information (including name, address, phone number, and/or email) to provide these services and Ipsen may also contact me to solicit my opinions regarding SOMATULINE® DEPOT and Ipsen’s products and services. I understand that my cell phone carrier’s standard rates may apply for calls to my cell phone. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. I may revoke this authorization, by calling 866.435.5677 or sending a request in writing to: IPSEN CARES, 11800 Weston Parkway, Cary, NC 27513. 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 Ipsen harmless in the event that such other person alleges that they did not give consent.

Patient Name *

Date of Birth *

Home Phone # *

Mobile Phone #

Required if patient is under 18 years of age.

Caregiver/Legal Guardian Name

Relationship to Patient

Caregiver/Legal Guardian Phone #

We are collecting personal information in order to fulfill your request. Please see Ipsen’s privacy policy at https://www.ipsen.com/us/privacy-policy/.

SOMATULINE DEPOT is a registered trademark of IPSEN PHARMA S.A.S.
IPSEN CARES is a registered trademark of Ipsen S.A.
©2021 Ipsen Biopharmaceuticals, Inc. September 2021 SMD-US-003651 V 2.0

IPSEN CARES PATIENT AUTHORIZATION FORM

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