ࡱ> #`  bjbj 8,"bbbbbbbv>*>*>*>*R+v^9fZ,l0l0l0l0K1H1,158787878787878$:h,=[8b1G1K111[8bbl0l092221Rbl0bl058215822bb2l0N, |>*)2.2 4,.90^92=W2=2=b 311211111[8[82 111^91111vvv$vvvvvvbbbbbb Patient Enrollment: Tracleer( Access Program (T.A.P.)PO Box 826, South San Francisco, CA 94083-0826 Phone 1-866-228-3546 or Fax 1-866-279-0669When this form is submitted to the Tracleer Access Program (T.A.P.), the information will be entered into the T.A.P. database and forwarded to the specialty pharmacy designated below. The specialty pharmacy may follow up as needed with physicians and eligible patients. Prescription FORMCHECKBOX  Tracleer 62.5 mg (66215-0101-06) Refills #:  FORMTEXT      FORMCHECKBOX  Tracleer 125 mg (66215-0102-06) Refills #:  FORMTEXT     I certify that I am prescribing Tracleer (bosentan) for this patient for a medically appropriate use in the treatment of pulmonary arterial hypertension, as described in the Tracleer full prescribing information. I have reviewed the liver and pregnancy warning with the patient and commit to undertaking appropriate blood testing for monitoring liver function in this patient and testing for pregnancy (if the patient is a female of childbearing potential). Directions for use:  FORMTEXT       Dispense as Written Prescriber s signature: ____________________________ Date: _____________Ship-to directions:  FORMCHECKBOX  Physician office  FORMCHECKBOX  Patient s home  FORMCHECKBOX  HospitalAddress (no PO Box):  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Ship Attn:  FORMTEXT       DiagnosisPrimary:  FORMTEXT       Secondary:  FORMTEXT      ICD  FORMTEXT       ICD  FORMTEXT       Specialty PharmacyIndicate specialty pharmacy preference:  FORMTEXT       For a current list of pharmacies, please call 1-866-228-3546. If no preference is indicated, this referral will be sent to the appropriate specialty pharmacy based on the patient s existing benefits. Physician InformationName:  FORMTEXT      DEA #:  FORMTEXT      Complete section below only if you are a new prescriber or your contact information has changed.Name of facility:  FORMTEXT      MD specialty:  FORMTEXT      Tax ID #:  FORMTEXT      Contact name:  FORMTEXT      State license #:  FORMTEXT      Phone #:  FORMTEXT      Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Fax #:  FORMTEXT       Patient InformationName:  FORMTEXT      SSN:  FORMTEXT      DOB:  FORMTEXT      Address:  FORMTEXT      Phone #:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Sex:  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleCaregiver name:  FORMTEXT      Relationship:  FORMTEXT      Alternate Phone #:  FORMTEXT       Insurance InformationPrimary insurance company:  FORMTEXT      Phone #:  FORMTEXT      Name of insured:  FORMTEXT      Policy #:  FORMTEXT      Group/Policy #:  FORMTEXT      Prescription coverage name:  FORMTEXT      Phone #:  FORMTEXT      Policy #:  FORMTEXT      Group/Policy #:  FORMTEXT      Secondary insurance name:  FORMTEXT      Phone #:  FORMTEXT      Name of insured:  FORMTEXT      Policy #:  FORMTEXT      Group/Policy #:  FORMTEXT       By signing below, I allow Actelion and other entities involved with T.A.P., and their employees, distributors, or agents, to use and give out my health information to run the medication-access program and any related patient-assistance programs. I also allow my health plans, other payers, pharmacies, and other healthcare providers to give my health information to Actelion as needed to help find ways to pay for Tracleer, or for treatment or healthcare operations purposes. I agree that my health information may be given to insurance companies, the Food and Drug Administration, or other government agencies (to comply with state and federal regulation or coverage eligibility requirements), charities, or other parties as necessary to participate in the medication-access program and run the program. I know that this program may be changed or stopped at any time. I know that completing this form does not ensure that I will receive therapy. I understand that Actelion does not promise to find ways to pay for my Tracleer, and I know that I am responsible for the costs of my care. I also certify that the information I have set forth in this application is true, correct, and complete. Patient/guardian signature:Date:REQUIRED: PLEASE SUBMIT COPIES OF PATIENTS CURRENT MEDICAL AND PRESCRIPTION CARDS WITH THIS FORM. ( 2007 Actelion Pharmaceuticals US, Inc. All rights reserved. 07 306 01 00 0707 Authorization For Use or Disclosure of Health Information Fax To: 1-866-279-0669 Patient Name: _____________________________________________ Date of Birth: ____________ I have elected to participate in the following program(s):  FORMCHECKBOX Sure Steps"! is a patient support and educational program for patients with pulmonary arterial hypertension who are on Tracleer (bosentan). FORMCHECKBOX LabTrac is a program designed to assist your physician in managing your care. LabTrac allows your physician to centrally review all of your laboratory results associated with your treatment on Tracleer. FORMCHECKBOX Market Research provides patients with an opportunity to share insights on their experience with PAH. Patients choosing to participate will be compensated for their time.By signing below, I authorize Actelion, Inc. and agents operating the above described Programs (collectively, "Actelion") to use and disclose any and all of my individually identifiable health information, including, but not limited to, any and all spoken or written facts about my health, medications, insurance benefits, and all records maintained by Actelion in connection with the Programs ("Health Information"), as described in this authorization. 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   44 Haf4pytfg $Ifgdfg "$&024@TVj̵m̵SmE̵h/&CJOJQJ^JaJ2j,h3hfg5CJOJQJU^JaJ7jh3h95CJOJQJU^JaJmHnHu2jX,h3hfg5CJOJQJU^JaJ#h3hfg5CJOJQJ^JaJ,jh3hfg5CJOJQJU^JaJ h,'^hfgCJOJQJ^JaJ#h,'^hfg5CJOJQJ^JaJ h,'^hOU CJ OJQJ^JaJ jlnxz|~g$h$i$$$$$ϳϢo^oLo:) h,'^hCJOJQJ^JaJ#h,'^h5CJOJQJ^JaJ#h,'^h}5CJOJQJ^JaJ h,'^hfgCJOJQJ^JaJ h,'^h}CJOJQJ^JaJ h,'^hOU CJ OJQJ^JaJ h,'^hfgCJ OJQJ^JaJ h,'^hfgCJOJQJ^JaJ7jh3h95CJOJQJU^JaJmHnHu,jh3hfg5CJOJQJU^JaJ2j@-h3hfg5CJOJQJU^JaJ4|~h$i$9444gdkd-$$IfH4      B\I!,  t0      -44 Haf4p(ytfg $Ifgdfgi$$$$$$@%B%UNNNNxgdkd.$$Ifl  0,=   tMM0  $-644 l` MapMMyt} $Ifgd}$$$%-%?%A%B%C%|%}%~%%%%T&ʼraRrRC2 h9hqjCJOJQJ^JaJh* hqjCJOJQJ^Jh* hcCJOJQJ^J h* hcCJ OJQJ^JaJ #h* hc5CJ OJQJ^JaJ h* hqjOJQJ h,'^hqjCJOJQJ^JaJh5CJOJQJ^JaJhCJOJQJ^JaJhO!CJOJQJ^JaJ h,'^hCJOJQJ^JaJ& jh,'^hCJOJQJ^JaJ h,'^hCJOJQJ^JaJB%~%%%%%V&z&'zuun`U x$Ifgdc$x$Ifa$gdcxgdqjgdqj|kd/$$Ifs0* N     t0#+44 sa4ytc $IfgdqjT&V&X&t&v&x&z&&&v'x'''''еkYH6Hkе#h/&hcCJH*OJQJ^JaJ h9hcCJOJQJ^JaJ#h9hc5CJOJQJ^JaJ&h9hc5>*CJOJQJ^JaJ&h3hc5>*CJOJQJ^JaJCjB0hoXhoX5CJOJQJU^JaJfHq 4h3hc5CJOJQJ^JaJfHq =jh3hc5CJOJQJU^JaJfHq h9hCJOJQJ^JaJ'''(((e)<Ukd1$$Ifs0,<) t44 sa+ytc x$Ifgdc$x$Ifa$gdcUkd0$$Ifs0,<) t44 sa+ytc'''''((((((((e)f)f+ݾjH757U h9hqjCJOJQJ^JaJCjt2hoXhoX5CJOJQJU^JaJfHq 4h3hc5CJOJQJ^JaJfHq h9hcCJOJQJ^JaJ&h9hc5>*CJOJQJ^JaJ&h3hc5>*CJOJQJ^JaJ=jh3hc5CJOJQJU^JaJfHq Cj[1hoXhoX5CJOJQJU^JaJfHq e)f),+.мҼ $IfgdcxgdqjUkd2$$Ifs0,<) t44 sa+ytc mation to Program representatives and third parties that work with Actelion in connection with the Program (the "Authorized Persons") in order for the Authorized Persons to provide me with marketing, promotional or educational information with respect to the Program, PAH, related conditions and/or treatment options (the "Information"). I specifically allow my Health Information to be used and given out by Actelion to the Authorized Persons for marketing purposes as described in this Authorization. I agree that I may be contacted by the Authorized Persons by phone, by mail, by e-mail or through other means with respect to the Information. I understand that Actelion does not sell my Health Information to the Authorized Persons but that the Authorized Persons may receive remuneration from Actelion in connection with their involvement with the Program, including the dissemination of the Information. I know and agree that the Authorized Persons may use and see my Health Information as described above. I understand that my Health Information may also be given out as needed to deal with safety, my treatment, adverse events, and related issues to the extent allowed under applicable law or as previously consented to in writing by me. I understand that if my Health Information is given out as allowed in this authorization, federal and state privacy laws may not protect it if those laws do not apply to the recipients. This authorization expires on January 1, 2010. If I change my mind before that time and do not want Actelion to continue to share my Health Information, I can notify Actelion of such revocation in writing, signed by me or on my behalf and delivered to Actelion at 5000 Shoreline Court, Suite 200, South San Francisco, CA 94080. If I notify Actelion in writing to stop sharing my Health Information, such notice will be effective upon receipt by Actelion but will not change any actions that Actelion or others took in reliance upon this authorization before my effective revocation of this authorization. I know that I may refuse to sign this authorization. My decision not to sign this authorization will not affect my ability to get treatment from my health care providers, or to seek payment or eligibility for benefits. I understand that I have a right to receive a copy of this authorization. I agree that a copy of this authorization may be treated as a signed original. Signature of Patient:Date:Personal Representatives Section: If this form is signed by someone who is not the participant listed at the top of this authorization, describe the signer s legal authority to act for the participant:  2007 Actelion Pharmaceuticals US, Inc. 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