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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.

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