Sign Up For EntyvioConnect

1. Your Current Treatment

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Which condition have you been diagnosed with?*

Ulcerative Colitis Crohn's Disease

Are you currently taking or about to start taking ENTYVIO?*

Yes No

2. Service Selection

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**In addition to getting access to emails with tips and advice, based on the information you provided, you can also sign up for the following EntyvioConnect services.** Check which services you would like to sign up for (optional):

Co-Pay & Insurance Help

Our co-pay and other financial resources, like the downloadable savings card, may help you save on out-of-pocket costs. Our experts can help navigate your insurance coverage and any eligibility requirements.

Connect with a Nurse Educator

Our Nurse Educators provide
one-on-one guidance, resources and support to help you get started and stay on track with your treatment as prescribed by your doctor. They cannot, however, provide medical advice.

Looks like you're interested in enrolling in the Co-Pay Program. Please answer the following questions:

Do you certify that you currently have commercial insurance that covers a portion of your prescription costs for ENTYVIO?*

Yes No

Do you certify that you are not enrolled in any federal or state healthcare program (Medicare, Medicaid, TRICARE, etc.), including a state pharmaceutical assistance program?*

Yes No

Do you certify that you will not seek reimbursement from any other plan or program (Flexible Spending Account [FSA], Health Savings Account [HSA], Health Reimbursement Account [HRA], etc.) for any out-of-pocket costs covered by the Co-Pay Assistance Program?*

Yes No

Do you understand that you or your doctor will need to submit your Explanation of Benefits (EOB) following each infusion, and that the Program cannot provide co-pay assistance without an EOB?*

Yes No

Co-Pay & Insurance Help

Co-Pay Program Terms and Conditions

The EntyvioConnect Co-Pay Program (“Co-Pay Program”) provides financial support for commercially insured patients who qualify for the Co-Pay Program. The Co-Pay Program cannot be used if patient is a beneficiary of, or any part of the prescription is covered by: 1) any federal, state, or government-funded healthcare program (Medicare, Medicare Advantage, Medicaid, TRICARE, etc.), including a state pharmaceutical assistance program (the Federal Employees Health Benefit (FEHB) Program is not a government-funded healthcare program for the purpose of this offer), 2) the Medicare Prescription Drug Program (Part D), or if patient is currently in the coverage gap, or 3) insurance that is paying the entire cost of the prescription. Patient may not seek reimbursement from any other plan or program (Flexible Spending Account [FSA], Health Savings Account [HSA], Health Reimbursement Account [HRA], etc.) for any out-of-pocket costs covered by the Co-Pay Program. Patient or healthcare provider may be required to submit an Explanation of Benefits (EOB) following each infusion to the Co-Pay Program. Takeda reserves the right to change or end the Co-Pay Program at any time without notice, and other terms and conditions may apply. Offer not valid for patients under 18 years of age. Assistance under the Co-Pay Program is not transferable. The Co-Pay Program only applies in the United States, including Puerto Rico and other U.S. territories, and does not apply where prohibited by law, taxed, or restricted. This does not constitute health insurance. Void where use is prohibited by your insurance provider. If your insurance situation changes you must notify EntyvioConnect at 1-844-368-9846. This offer is not transferable and is limited to one offer per person and may not be combined with any other coupon, discount, prescription savings card, rebate, free trial, patient assistance, or other offer. Not valid if reproduced.

Click here for a printable copy of the Co-Pay Program Terms and Conditions

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3. Your Contact Information

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To support you every step of the way, we will need to keep in contact with you. Please provide the following for our future communications:

First Name*

Last Name*

Email Address*

Primary Number*

Your information is safe.

Your Mobile Phone Number will be used to verify your account.

We will never share your details and you can unsubscribe at any time.

Date of Birth (mm/dd/yyyy)*

Gender*

Male Female

Address Line 1*

Address Line 2 (optional)

ZIP*

City*

State*

Your information is safe.

Your ZIP code will be used to verify your account.

We will never share your details and you can unsubscribe at any time.

4. Your Doctor's Information

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Please provide your doctor's information so we can help you manage your insurance and coverage, and identify available financial support options.

Doctor's First Name*

Doctor's Last Name*

Doctor's Phone Number*

Doctor's Address Line 1*

Doctor's Address Line 2 (optional)

Doctor's ZIP*

Doctor's City*

Doctor's State*

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5. Consent

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Patient HIPAA Authorization

HIPAA Authorization Information

By signing the Patient Authorization section of this EntyvioConnect Enrollment Form, I authorize my physician, health insurance, and pharmacy providers (including any specialty pharmacy that receives my prescription) to disclose my protected health information, including, but not limited to, information relating to my medical condition, treatment, care management, and health insurance, as well as all information provided on this form (“Protected Health Information”), to Takeda Pharmaceuticals U.S.A., Inc. and its present or future affiliates, including the affiliates and service providers that work on Takeda's behalf in connection with the EntyvioConnect Patient Support Program (the “Companies”). The Companies will use my Protected Health Information for the purpose of facilitating the provision of the EntyvioConnect Patient Support Program products, supplies, or services as selected by me or my physician and may include (but not be limited to) verification of insurance benefits and drug coverage, prior authorization education, financial assistance with co-pays, patient assistance programs, and other related programs. Specifically, I authorize the Companies to 1) receive, use, and disclose my Protected Health Information in order to enroll me in EntyvioConnect and contact me, and/or the person legally authorized to sign on my behalf, about EntyvioConnect; 2) provide me, and/or the person legally authorized to sign on my behalf, with educational materials, information, and services related to EntyvioConnect; 3) verify, investigate, and provide information about my coverage for ENTYVIO, including but not limited to communicating with my insurer, specialty pharmacies, and others involved in processing my pharmacy claims to verify my coverage; 4) coordinate prescription fulfillment; and 5) use my information to conduct internal analyses.

I understand that employees of the Companies only use my Protected Health Information for the purposes described herein, to administer the EntyvioConnect Patient Support Program or as otherwise required or allowed under the law, unless information that specifically identifies me is removed. Further, I understand that my healthcare provider may receive financial remuneration from Takeda Pharmaceuticals U.S.A. for marketing services. I understand that Protected Health Information disclosed under this Authorization may no longer be protected by federal privacy law. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization and that instructions for doing so are contained in Takeda's Website Privacy Notice. I understand that such cancellation will not apply to any information already used or disclosed through this Authorization. This Authorization will expire within five (5) years from the date it is signed, unless a shorter period is provided for by state law. I understand that I may refuse to sign this Authorization and that refusing to sign this Authorization will not change the way my physician, health insurance, and pharmacy providers treat me. I also understand that if I do not sign this Authorization, I will not be able to receive EntyvioConnect Patient Support Program products, supplies, or services.

Digital Signature

Signature must match First Name and Last Name you provided previously: .

First Name

Last Name

EntyvioConnect Patient Support Program Enrollment

EntyvioConnect Patient Support Program Enrollment Terms and Conditions

Enroll me in the EntyvioConnect Patient Support Program (the “Program”). I have read and understand the applicable terms and conditions. I certify that all the information provided on this form is accurate and complete, and I agree to notify the Program immediately if my medical or prescription drug coverage changes in any way. I understand that Takeda and its business partners will use my personal information to enroll me in the Program, provide the support I am asking for, and offer related services to me. I authorize Takeda, its affiliates and business partners to use my personal information to provide me with information and offers related to ENTYVIO, the diseases and the conditions it treats, and related treatment options. In addition to information about ENTYVIO and related health conditions, I understand this may include information about clinical trials and market research opportunities, and other support services or programs Takeda may in the future develop for patients. I also authorize Takeda to use my de-identified information to help Takeda improve and develop products, services, materials, and programs or for health economic outcomes and market research. I understand that I may revoke my permission at any time. To learn how Takeda will use and protect my personal information, I acknowledge that I have reviewed Takeda's Privacy Notice.

I have read, understand, and agree to the use of my personal information for the purposes described above.

Digital Signature

Signature must match First Name and Last Name you provided previously: .

First Name

Last Name

1. Your Current Treatment

Which condition have you been diagnosed with?*

Are you currently taking or about to start taking ENTYVIO?*

2. Service Selection

In addition to getting access to emails with tips and advice, based on the information you provided, you can also sign up for the following EntyvioConnect services. Check which services you would like to sign up for (optional):

Co-Pay & Insurance Help

Connect with a Nurse Educator

Text Message Treatment Reminders

Looks like you're interested in enrolling in the Co-Pay Program. Please answer the following questions:

Co-Pay & Insurance Help

Co-Pay Program Terms and Conditions

3. Your Contact Information

4. Your Doctor's Information

5. Consent

Patient HIPAA Authorization

HIPAA Authorization Information

Digital Signature

EntyvioConnect Patient Support Program Enrollment

EntyvioConnect Patient Support Program Enrollment Terms and Conditions

Digital Signature

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Share with Your Friends and Family:

**In addition to getting access to emails with tips and advice, based on the information you provided, you can also sign up for the following EntyvioConnect services.** Check which services you would like to sign up for (optional):