DYS US 004420 Enrollment Form

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HOW TO ENROLL IN IPSEN CARES PATIENT SUPPORT PROGRAM

IPSEN CARES provides a single point of contact for patients and their doctor’s office.

Please note: This form will take 10 minutes to complete. There is a requirement for two signatures - first the patient, then the HCP office.

Instructions for Patients

Your Healthcare Provider will complete the Steps Outlined in Light Green.
You need to complete Steps 1, 2, 3 and 8 Outlined in Dark Green on the Enrollment Form.
Fill out all sections completely. Required fields must be completed prior to submission of the form.
Required fields are marked with an asterisk.

STEP 1: Fill out the Patient Information Section in Step 1.
STEP 2: Fill out the Insurance Information Section in Step 2.
STEP 3: Fill out the IPSEN CARES Copay Program Section in Step 3.
STEP 4: Sign the PATIENT AUTHORIZATION AND ADDITIONAL PRODUCT AND SUPPORT INFORMATION box under Step 2 after you read the information in Step 8

Instructions for Prescribers

Fill out the Prescriber Information Sections in Steps 4-7.
Sign and date the PRESCRIBER/OFFICE MANAGER ATTESTATION at the end of Step 7B.
Required fields are marked with an asterisk.

Once a completed Enrollment Form is received, an IPSEN CARES Patient Access Specialist will perform a benefits verification and review the patient’s coverage and out-of-pocket responsibility with both the HCP and the patient typically within 1 business day. To learn more about IPSEN CARES and support offerings, please call 866-435-5677, 8:00 am to 8:00 pm ET Monday through Friday or visit www.ipsencares.com.

Eligible patients using commercial insurance can save on out-of-pocket Ipsen medication costs. Please see Patient Eligibility & Terms and Conditions.

I attest that I am not enrolled in any health insurance plan from any state or federally funded programs (including, but not limited to, Medicare or Medicaid, VA, DOD, or TRICARE) and agree to the Terms and Conditions of the Copay Program.

I would like IPSEN CARES to check my eligibility for, and enroll me into, the Dysport Copay Program if the results of this benefit verification determine that I have commercial or private health insurance.

Prescriber Name *

State License #

Tax ID # *

NPI # *

Medicaid Provider # (Required if Medicaid Patient)

Office / Institution *

Specialty *

Office Contact and Title *

Street Address *

City *

State *

Zip *

Phone # *

Fax # *

Email *

Preferred Method of Contact

Phone

Fax

Best time to Contact

Morning

Afternoon

Evening

Are you going to utilize Specialty Pharmacy or Buy & Bill? *

Specialty Pharmacy

Buy & Bill

Complete the following if you are going to use a Specialty Pharmacy.

If you would like IPSEN CARES to triage the prescription to a Specialty Pharmacy, complete the Prescription information in Step 7A.

Preferred Specialty Pharmacy

Was Rx sent to a Specialty Pharmacy already? *

Yes

If yes, please provide the name of the Specialty Pharmacy

Primary ICD-10 Code *

Secondary ICD-10 Code (optional)

(Complete this section if you would like IPSEN CARES to triage the prescription to a Specialty Pharmacy.)

PRESCRIPTION Dysport® (abobotulinumtoxinA)

Patient Name *

Date of Birth *

Site of Care

Physician Office

Hospital/Outpatient

Other

Please fill in the requested information in the table below.

Dysport Strength	Route of Administration	Frequency	Directions	Quantity	Refills
	Intramuscular Injection

Dysport Strength
Route of Administration	Intramuscular Injection
Frequency
Directions
Quantity
Refills

(The Prescriber must sign if this form is to be used as a prescription to be triaged to a Specialty Pharmacy, to enroll a patient for free goods as part of the Patient Assistance Program (PAP), or to enroll a patient for free goods as part of the Temporary Patient Assistance Program (TPAP). If the request is limited to Benefit Verification or Copay Assistance Support, the Prescriber, or an individual acting at the direction of the Prescriber and involved in the patient’s care, such as an Office Practice Manager, Financial Coordinator, Financial Counselor, Patient Assistance Coordinator, Patient Navigator, Social Worker, Insurance Coordinator, Patient Coordinator, or Patient Care Advocate, may sign this form.)

By signing below, I certify that a prescription signed by a licensed prescriber is on file for the above therapy and that the patient named on this form has provided the necessary authorization to release the information herein and medical and/or patient information relating to Dysport® therapy to Ipsen and its agents or contractors for the purpose of seeking reimbursement for Dysport® therapy, assisting in initiating or continuing Dysport® therapy, and/or evaluating the patient’s eligibility for Ipsen’s patient support programs administered by IPSEN CARES. I authorize Ipsen to be my agent and to forward the above prescription, by fax or other mode of delivery, to the pharmacy chosen by the patient named on this form. For the state of New York, copies of all prescriptions should be on official New York state prescription forms.

I certify that any medications received from Ipsen in connection with any IPSEN CARES program will be used only for the named patient. These medications will not be offered for sale, trade, or barter. Additionally, no claim for reimbursement will be submitted concerning any medications provided by Ipsen, or any services provided by IPSEN CARES, to any payor, including Medicare, Medicaid, or any other federal or state health insurance program, nor will any medications be returned for credit. If the named patient does not return for therapy, product will be returned to Ipsen. I acknowledge that I have assisted the patient in enrolling in IPSEN CARES exclusively for purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort.

Name *

Title *

I authorize my/the patient’s healthcare providers (including those pharmacies that may receive my/the patient’s prescription for Dysport®) to disclose personal health information (“PHI”) about me/the patient, including health information relating to my/the patient’s 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/the patient in IPSEN CARES; (2) establish my/the patient’s benefit eligibility and potential out-of-pocket costs for Dysport®; (3) communicate with my/the patient’s healthcare providers and health plans about my/the patient’s treatment plan; (4) provide support services, including patient education and financia assistance for Dysport®; (5) help get Dysport® shipped to my/the patient’s healthcare provider; and (6) facilitate my/the patient’s participation in Dysport® patients programs as I have requested or may request. 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/the patient am/is on Dysport® therapy. I consent to being contacted by an IPSEN CARES program representative in order for the program to obtain further information or clarification regarding any adverse event I/the patient may experience.

I understand that once my/the patient’s PHI has been disclosed to Ipsen, privacy laws may no longer restrict its use or disclosure; however, Ipsen agrees to protect my/the patient’s information by using and disclosing it only for the purposes described above or as required by law. I understand that my/the patient’s healthcare providers may receive remuneration from Ipsen in exchange for my/the patient’s PHI and/or for any therapy support services provided to me/the patient. I can withdraw this authorization by calling IPSEN CARES at 1-866-435-5677 or mailing a letter requesting such revocation to IPSEN CARES, 11800 Weston Parkway, Cary, NC 27513, but it will not 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 understand that I may refuse to sign this form and, if I do so, I/the patient will not be able to participate in IPSEN CARES programs, but it will not affect my/the patient’s eligibility to obtain medical treatment, my/the patient’s ability to seek payment for this treatment, or affect my/the patient’s 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 will receive a copy of the signed authorization.

Additional Product And Support Information

Text Adherence Program

To the extent that I have opted in under step one of this form, 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 or advertise 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 DYSPORT®, 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 DYSPORT® 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.

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/.

Dysport® (abobotulinumtoxinA) for injection, for intramuscular use, 300- and 500-unit vials.
DYSPORT is a registered trademark of Ipsen Biopharm Limited.
IPSEN CARES is a registered trademark of Ipsen S.A.
©2021 Ipsen Biopharmaceuticals, Inc. September 2021 DYS-US-004420 V 2.0

Please see accompanying full Prescribing Information, including Boxed Warning and Medication Guide.

HOW TO ENROLL IN IPSEN CARES PATIENT SUPPORT PROGRAM

Instructions for Patients

Instructions for Prescribers

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