By completing and submitting this form, you represent that your patient has requested and authorized the disclosure of their personal health information to Amgen and its agents for Amgen to provide the patient support services described in this paragraph. You represent that you have explained to the patient, and the patient indicated they understand and have consented to, the following: 1) Amgen and its agents will use the patient’s name, date of birth, contact information, prescriptions, and other necessary health information for reimbursement services related to this prescription, including for the Amgen SupportPlus co‐pay program, and to contact the patient directly for the administration of these patient support services 2) the patient can withdraw their consent by contacting Amgen at privacy@amgen.com or visiting www.amgen.com/DataSubjectRights, but if the patient does not agree to, or withdraws consent for, these uses and disclosures, the patient cannot receive these patient support services for this medication which necessarily requires Amgen to process the patient’s personal information; and 3) the patient can view more details about Amgen’s privacy practice at www.amgen.com/privacy. You must share this copay information and the program’s Terms & Conditions with the patient upon receipt of the offer.