PATIENT-SIGNED DATA PRIVACY CONSENT FOR CSL Behring’s Support Programs:
By signing this authorization, I authorize my health plans, physicians and staff, other healthcare providers, and pharmacy providers
(collectively, my “Providers”) to disclose information, including but not limited to, personal health information about me or my minor
child, including information related to my or my child’s medical condition, treatment, care management, and health insurance coverage and
claims, any prescription (including fill/refill information), and any other information disclosed in connection with the Services
(as defined below) (“Personal Health Information”), to CSL Behring and its representatives, agents, and contractors, including CSL Behring’s
support program(s) (collectively “CSL Behring Entities”) for the purposes of:
establishing eligibility for insurance benefits including but not limited to coverage for prescription drugs;
evaluation and enrollment in one or more financial assistance program(s) offered by CSL Behring Entities, such as a co-pay mitigation
program and/or patient assistance programs (if one or more of such programs apply to my treatment with a CSL Behring therapy);
enrollment in available patient services programs offered by CSL Behring Entities;
communication about my treatment with me or my Providers, including by contacting me directly to facilitate the dispensing of medication
and scheduling shipments and refill reminders;
providing product support and adherence services through CSL Behring Entities;
evaluating the effectiveness of CSL Behring’s support program(s); and
any other related support, education, and assistance services related to my treatment with CSL Behring therapy and/or living with my disease
(collectively, the “Services”).
Further, I authorize any of the CSL Behring Entities to contact me by mail, telephone and/or SMS/text message, or e-mail for relevant follow-up to any
of the aforementioned Services. CSL Behring Entities include but are not limited to brand specific support through hub service providers, pharmacy
service providers, nurse self-infusion training providers and/or nurse adherence providers, as well as other entities under contract with CSL Behring
to support these or similar aspects of the Services. I understand that these CSL Behring Entities may collect Personal Health Information from me for
I understand that once my Personal Health Information or other personal information is disclosed to the CSL Behring Entities under this authorization,
it may no longer be protected by state and/or federal privacy laws and may be further disclosed by the CSL Behring Entities. However, I understand that
the CSL Behring Entities will disclose my Personal Health Information only for the limited purposes described above, or as I may further authorize in writing,
or as permitted or required by law. I understand that data related to my enrollment in any CSL Behring program may be collected, analyzed and shared among CSL
Behring Entities. I also understand that CSL Behring Entities may receive compensation from CSL Behring in connection with the Services.
I understand that my pharmacy Providers, including those Providers who dispense free trials as part of the Services or commercially-reimbursed doses of
CSL Behring products, may disclose to the CSL Behring Entities certain Personal Health Information regarding the dispensing of my prescription and that
such disclosure may result in remuneration to my pharmacy Provider(s). If necessary or if requested by my prescriber, I authorize CSL Behring Entities
to forward my prescription to a dispensing pharmacy on my behalf.
I understand that I may refuse to sign this authorization. I understand, however, that if I do not sign this authorization, I may not be able to receive
Services through CSL Behring Entities. I understand that my treatment with a CSL Behring therapy (other than participation in a free trial program), payment
for treatment, insurance enrollment, or eligibility for insurance benefits are not conditioned upon my agreement to sign this authorization. I understand that
Services provided by CSL Behring are not insurance and that CSL Behring has the right to rescind, revoke or amend any service at any time without notice.
I understand that I am entitled to a copy of this authorization.
I understand that if CSL loans me durable medical equipment or other medical equipment through the Services, CSL reserves the right to seek reimbursement
from me for all unreturned DME or equipment.
I understand that I may change my mind and cancel this authorization at any time by writing a letter requesting such cancellation to CSL Behring c/o
Patient Services P.O. Box 61501 King of Prussia, PA 19406 or by calling the CSL Behring Customer Affairs toll free number 1-888-508-6978 and that this
cancellation will end my participation in CSL Behring Services and will not apply to any information already used or disclosed through this authorization
before notice of the cancellation is received by CSL Behring Entities. This authorization expires five (5) years from the date signed, or earlier,
if required by state law. CSL Behring will not retain this data beyond the maximum period allowed by law.
I understand that, under certain circumstances, by law I may have certain rights regarding CSL Behring’s use of my or my minor child’s data.
I may have the right to receive information about what data CSL Behring has collected about me or my minor child. I may have the right to ask CSL Behring
to delete certain personal information about me or my minor child, but only when CSL Behring does not have a legal reason for retaining such personal information.
I understand that if I exercise these rights, I will be asked to verify my identity, that if someone else will exercise my rights on my behalf, that they will
need to prove that they have your permission to do so. I understand that to exercise my rights, I may contact CSL Behring through
https://privacyinfo.csl.com/ or toll free by phone at (833) 704-0018. For more information about how CSL Behring handles personal information, I understand