Stay Connected | POTELIGEO® (mogamulizumab-kpkc)

POTELIGEO is a prescription medicine used to treat Mycosis Fungoides (MF) or Sézary Syndrome (SS) in adults who have tried at least one prior medicine (taken by mouth or injection) and it did not work or the disease has come back.

Tell us what best describes you from the following two options:

To stay connected with POTELIGEO, you have the option of enrolling in Kyowa Kirin Cares to receive comprehensive support including phone calls, texts, and email from dedicated specialists.

I’m currently taking or caring for someone taking POTELIGEO

Enroll in Kyowa Kirin Cares Patient Support Program

Kyowa Kirin Cares provides you with a dedicated team that offers personal and comprehensive support for patients who have been prescribed POTELIGEO, caregivers, and healthcare providers—from access and reimbursement assistance to ongoing support during treatment. Our specialists are committed to helping you, though your doctor will continue to provide medical advice and act as your primary point-of-care. Take the next step and complete your enrollment below.

*Required field.

Patient First Name*

Patient Last Name*

Patient Email Address*

Patient Address*

City*

State*

ZIP Code*

Mobile Phone*

Select what best describes you*

Mycosis Fungoides (MF)
Sézary Syndrome (SS)
Unknown

By checking this box, I confirm this is my phone number and agree to subscribe to the Kyowa Kirin Cares Text Message program. I understand the amount of texts I receive may vary based on the progress of my enrollment. Full Text Message program terms and conditions: https://www.kyowakirincares.com/SMS_Terms.pdf

*By checking this box, I agree that Kyowa Kirin, or companies acting on its behalf, may send me news and updates about POTELIGEO and Kyowa Kirin products, clinical trials, programs, and other information that may be of interest to me. I may opt out at any time, instructions for which will be included in each email I receive. I understand that Kyowa Kirin, and companies acting on its behalf, will not sell or rent my personally identifiable information, and will only use my personal information as described in the Kyowa Kirin Privacy Policy and Terms of Use.

*Checking this box will launch the Patient Authorization for Health Information Use and Disclosure. This consent enrolls you in patient support, as well as nurse and financial assistance services. By checking this box and signing the Authorization form, you acknowledge that you have read the terms associated with the Patient Authorization for Health Information Use and Disclosure, and that you agree to them.

Patient Authorization for Health Information Use and Disclosure
By clicking submit, I authorize each of my physicians, pharmacists, including any specialty pharmacy that receives my prescription for POTELIGEO (mogamulizumab-kpkc) and other healthcare providers (together “Healthcare Providers”) and each of my health insurers (together, “Insurers”) to disclose my Protected Health Information, including but not limited to medical records, information related to my medical condition and treatment, my health insurance coverage, my name, address, telephone number, Social Security number, insurance plan and or group numbers (together, “Protected Health Information”) to Kyowa Kirin, its affiliated companies, vendors, agents, collaboration partners, and representatives (together, “Kyowa Kirin”) including providers of alternate sources of funding for prescription drug costs, and other service providers supporting Kyowa Kirin Cares Support Services (the “Program”) for Healthcare Providers and patients for the purposes described below.

Specifically, I Authorize disclosure of my Protected Health Information in order to:

Enroll me in, and contact me about Kyowa Kirin Cares Support Services (“Program”), including online support, financial assistance services, co-pay assistance, nurse services, and compliance and persistency services,
Communicate with my Healthcare Providers and Insurers about benefits, coverage and medical care, including compliance with Product treatments,
Locate a specialty pharmacy that can fill my prescription and facilitate dispensing of my prescription by such pharmacy,
Provide me with educational materials, information and services related to my treatment experience with POTELIGEO and my condition,
Contact me and leave messages about my use of POTELIGEO and my medical care,
Verify, investigate, assist with, and coordinate my coverage for POTELIGEO with my Insurers,
Coordinate prescription fulfillment,
Conduct surveys, data analytics, market research and other internal business activities related to the Program, POTELIGEO, and other Kyowa Kirin products and programs, and
Contact me as otherwise required or permitted by law.

I understand that pharmacies that ship my medication may be paid to share this information with the Program to help provide the offerings requested for me. Once my Protected Health Information has been disclosed to Kyowa Kirin, I understand that federal privacy laws no longer protect the information. However, Kyowa Kirin agrees to protect my Protected Health Information by using and disclosing it only for the purposes described in this authorization or as permitted by law.

I understand that I may refuse to sign this Authorization. My choice about whether to sign will not change the way my Healthcare Providers or Insurers treat me, but I will not have access to the Program and the services provided by Kyowa Kirin under the Program. If I refuse to sign the Authorization, or revoke my authorization later, I understand that this means I will not be able to participate or receive assistance from the Program.

This Authorization will last for a period of five (5) years (unless earlier termination is required by applicable state law). I understand that I may cancel this Authorization at any time in the future, except to the extent that actions have been taken in reliance on the authorization, by mailing a request to 2730 S. Edmonds Lane, Suite 300 Lewisville, TX 75067, via fax at 844-267-5848, or by calling 833-552-2737. I understand that revoking this Authorization will end further uses and disclosure of my Protected Health Information by the parties identified above except to the extent those uses and disclosures have been made in reliance upon this Authorization as permitted by applicable law. I am entitled to receive a copy of this Authorization.

The personal and health insurance I have provided on this form is complete and accurate to the best of my knowledge. I will update my information promptly if any of the information reflected on this Form changes by contacting the Program at 833-552-2737.

Type
Draw

If you are not yet on treatment,
you may sign up to receive information by email.

I’m not currently taking or caring for someone taking POTELIGEO

Receive tools, resources, and updates from POTELIGEO

Take the next step to receive helpful resources and information about POTELIGEO, future events with MF or SS experts and existing POTELIGEO patients, as well as how to get started on POTELIGEO.

*Required field.

First Name*

Last Name*

Email Address*

Discover your options to stay connected with POTELIGEO

Tell us what best describes you from the following two options:

Enroll in Kyowa Kirin Cares Patient Support Program

Receive tools, resources, and updates from POTELIGEO