Authorization to Use and Disclose Personal Health Information and to Conduct Patient Support
I authorize my health plans, physicians, pharmacies, and other healthcare providers (collectively, my
“Providers”) to disclose my personal health information relating to my use of KYNMOBI (apomorphine HCl)
sublingual film, including my medical condition, treatment, care management, as well as the information
provided on this form (collectively, “Personal Health Information” or “PHI”), to Sunovion Pharmaceuticals
Inc. and its representatives, agents, and contractors that act on behalf of Sunovion (collectively,
“Sunovion”) so that Sunovion may use the information to enroll me in (including verifying my eligibility, as
applicable), facilitate my participation in, and administer KYNMOBI™ KYNNECT and any other applicable KYNMOBI
patient support programs that may be implemented by Sunovion (collectively, “KYNMOBI Patient Support”). As
part of this, Sunovion may use and disclose my Personal Health Information to:
Provide all KYNMOBI Patient Support for which I am eligible and have not opted out of and, where
applicable, as prescribed by my doctor or other healthcare provider;
Communicate with my Providers and other third parties as needed to facilitate the provision of KYNMOBI
Patient Support;
Contact me and my designated representative(s) regarding this form and my enrollment and participation
in KYNMOBI Patient Support, and provide me with related patient support communications, including by
mail, email, fax, telephone call, voicemail, text message (including calls and text messages made with
an automatic telephone-dialing system or a prerecorded voice) (up to 5 messages per week) (standard
message and data rates may apply; you may opt out at any time by replying “STOP”) and through messages
left for me that disclose that I take or may take KYNMOBI;
Provide me with educational information about KYNMOBI, in person, online, or by telephone, including
information and training regarding my use of KYNMOBI;
Monitor and evaluate KYNMOBI Patient Support for effectiveness, future program development, and other
administrative purposes; and
Monitor and report safety information about KYNMOBI, including in communications with the US Food and
Drug Administration and other government authorities.
I understand that once my Personal Health Information is disclosed to Sunovion under this authorization, it
is no longer protected by federal privacy laws and may be further disclosed by Sunovion. I understand that I
may refuse to sign this authorization and my healthcare provider(s) and health plan(s) will not condition my
treatment or benefits on whether I sign this Patient Authorization. I understand, however, that if I do not
sign this authorization, I may not be able to receive support through KYNMOBI™ KYNNECT. I understand that I
am entitled to a copy of this authorization. I understand that I may cancel this authorization at any time
by mailing a letter requesting such cancellation to Sunovion Pharmaceuticals Inc., 84 Waterford Drive,
Marlborough, MA 01752, but that this cancellation will not apply to any information already used or
disclosed pursuant to this authorization before the notice of the cancellation is received by Sunovion. This
authorization expires ten (10) years from the date of execution or upon such an earlier date as may be
mandated by state law, if applicable.
Thank you for registering at KYNMOBI!
We look forward to telling you more about KYNMOBI, a new medication to treat OFF episodes associated with Parkinson's disease, as it becomes available.
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A FULL-SERVICE RETAIL EXPERIENCE WITH WALGREENS
In-store pickup and mail* options for the Patient Starter Kit and 30-count cartons
Patient support service welcome letter and refill reminders
Benefits verification
Assistance with prior authorization requirements
Cash price option available for participating patients†
Price is $195 per 30-count carton‡
*Certain health plans do not cover, or participate in, this service. Check with the
health plan for further details. Walgreens Express is available on eligible prescriptions only. Most prescription orders
are available to be delivered to the patient’s home in 1–2 business days. Orders received by 4pm on
Friday, as well as requests made during the weekend, have an expected delivery day of Wednesday.
Prescriptions are not delivered on Sundays or holidays. Please note that while most prescriptions are
expected to be delivered in 1–2 business days, some deliveries may not be eligible for delivery due to
prescription type, delivery address, holidays, weather, or other delivery constraints.
†Participating patients agree not to submit claims to, or seek reimbursement from,
any third-party payer for the product; Medicare Part D patients must opt out of Part D coverage for the product for the
remainder of the plan year and agree not to count the purchase of the product toward their Medicare Part
D TrOOP. Participating patients agree to notify their Medicare Part D plan or other third party payor, as applicable, that they are participating in the offering.
‡Up to a maximum of 5 cartons per 30-day prescription.
