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Domain > www.takedapatientsupportenrollment-hematology.com
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DNS Resolutions
Date
IP Address
2025-05-21
52.205.197.48
(
ClassC
)
2025-10-16
54.210.170.26
(
ClassC
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Port 80
HTTP/1.1 302 Moved TemporarilyServer: awselb/2.0Date: Thu, 16 Oct 2025 00:02:12 GMTContent-Type: text/htmlContent-Length: 110Connection: keep-aliveLocation: https://www.takedapatientsupportenrollment-hematology.com:443/ html>head>title>302 Found/title>/head>body>center>h1>302 Found/h1>/center>/body>/html>
Port 443
HTTP/1.1 200 OKDate: Thu, 16 Oct 2025 00:02:12 GMTContent-Type: text/html; charsetutf-8Content-Length: 84284Connection: keep-aliveSet-Cookie: AWSALBUIlsYvPKKFSHpZmWnxIFvLvuhFt0PB3lqKVIoXgXALAGnMfGdnDttzx2L2NKJdHFKGpM71lhcR9ocvJse4K8clY2NHisrCZvfrZOebJlKxziKT0IsUMjUA0QGAr4; ExpiresThu, 23 Oct 2025 00:02:12 GMT; Path/Set-Cookie: AWSALBCORSUIlsYvPKKFSHpZmWnxIFvLvuhFt0PB3lqKVIoXgXALAGnMfGdnDttzx2L2NKJdHFKGpM71lhcR9ocvJse4K8clY2NHisrCZvfrZOebJlKxziKT0IsUMjUA0QGAr4; ExpiresThu, 23 Oct 2025 00:02:12 GMT; Path/; SameSiteNone; SecureX-DNS-Prefetch-Control: offX-Frame-Options: SAMEORIGINStrict-Transport-Security: max-age15552000; includeSubDomainsX-Download-Options: noopenX-Content-Type-Options: nosniffX-XSS-Protection: 1; modeblockETag: W/1493c-wOHIpLs/5WpjeWPIAuXzt7eyf8c !doctype html>html>head> meta charsetUTF-8> meta http-equivCache-Control contentmax-age86400> meta nameDescription contentCopay cards for patients. HCP for physicians.> meta nameviewport contentwidthdevice-width, initial-scale1, maximum-scale1> meta nameReferrer-Policy valuestrict-origin-when-cross-origin /> link relicon classcrx-wl-favicon hrefhttps://assets.copaysavingsprogram.com/whitelbl/crx-monogram.png sizes32x32> link relstylesheet hrefhttps://assets.copaysavingsprogram.com/whitelbl/wlsite.min.css/> link relstylesheet hrefhttps://cdn.jsdelivr.net/npm/pdfjs-dist@4.8.69/web/pdf_viewer.css crossoriginanonymous referrerpolicyno-referrer /> link relstylesheet hrefhttps://assets.copaysavingsprogram.com/takeda/hematology/home/Style.css> script srchttps://assets.copaysavingsprogram.com/whitelbl/bundle.min.js>/script> script srchttps://assets.copaysavingsprogram.com/whitelbl/ajv.min.js>/script> script srchttps://cdn.jsdelivr.net/npm/pdfjs-dist@4.8.69/build/pdf.mjs crossoriginanonymous referrerpolicyno-referrer typemodule>/script> script srchttps://cdn.jsdelivr.net/npm/pdfjs-dist@4.8.69/web/pdf_viewer.mjs crossoriginanonymous referrerpolicyno-referrer typemodule>/script> script> // Configure pdf.js worker and CORS settings if (typeof pdfjsLib ! undefined) { pdfjsLib.GlobalWorkerOptions.workerSrc https://cdn.jsdelivr.net/npm/pdfjs-dist@4.8.69/build/pdf.worker.mjs; } /script> script srchttps://assets.copaysavingsprogram.com/whitelbl/wlsite.min.js>/script> script srchttps://assets.copaysavingsprogram.com/takeda/hematology/home/Script.js>/script> script>(function(apiKey){(function(p,e,n,d,o){var v,w,x,y,z;opdpd||{};o._q;vinitialize,identify,updateOptions,pageLoad,track;for(w0,xv.length;wx;++w)(function(m){ omom||function(){o._qmv0?unshift:push(m.concat(.slice.call(arguments,0)));};})(vw); ye.createElement(n);y.async!0;y.srchttps://cdn.pendo.io/agent/static/+apiKey+/pendo.js; ze.getElementsByTagName(n)0;z.parentNode.insertBefore(y,z);})(window,document,script,pendo); // Call this whenever information about your visitors becomes available // Please use Strings, Numbers, or Bools for value types. pendo.initialize({ visitor: { id: // Required if user is logged in // email: // Recommended if using Pendo Feedback, or NPS Email // full_name: // Recommended if using Pendo Feedback // role: // Optional // You can add any additional visitor level key-values here, // as long as its not one of the above reserved names. }, account: {name:takeda-hematology,id:takeda-hematology,mfrId:copay-takeda-hematology,mfrName:copay-takeda-hematology} });})(63655611-9dc0-4b26-78a4-0553b12bce77);/script> /head>body> div classcontainer> link hrefhttps://fonts.googleapis.com/css2?familyRaleway:ital,wght@0,100..900;1,100..900&displayswap relstylesheet> link hrefhttps://fonts.googleapis.com/css2?familyMulish:ital,wght@0,200..1000;1,200..1000&displayswap relstylesheet> link relstylesheet hrefhttps://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css> div classcrx-gray-out>/div> div classcrx-loader>/div> header> div classcontainer> img image-srcheader-logo.png altHeader classcrx-wl-image> /div> /header> section classcrx-wl-patientform> div classcontainer> div classenrollmentWrap> div classenrollSteps step1 hideElement idpatientInfo> div classwelcomeWrap> h1>Takeda Patient Support Enrollment Form/h1> p>Takeda Patient Support is a program that can help eligible patients prescribed a Takeda Hematology product with education and resources to help access their therapy and support them throughout their treatment journey./p> /div> div classprogressBar> ul> li classactive> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> /li> /ul> /div> div classformWrap> img image-srcstep1-icon.png altPatient Information classcrx-wl-image stepIcon> h2>Please verify your Takeda Hematology product.sup>*/sup>/h2> div classcustom-list brandWrap fieldWrap> select namebrandName idcrx-wl-brandName> option value>Select/option> option valueAdvate>ADVATEsup>®/sup> Antihemophilic Factor (Recombinant)/option> option valueAdynovate>ADYNOVATEsup>®/sup> Antihemophilic Factor (Recombinant), PEGylated/option> option valueAdzynma>ADZYNMA (ADAMTS13, recombinant-krhn)/option> option valueFeiba>FEIBAsup>®/sup> (anti-inhibitor coagulant complex)/option> option valueHemofil M>HEMOFIL Msup>®/sup> Antihemophilic Factor (Human), Method M, Monoclonal Purified/option> option valueRecombinate>RECOMBINATEsup>®/sup> Antihemophilic Factor (Recombinant)/option> option valueRixubis>RIXUBISsup>®/sup> Coagulation Factor IX (Recombinant)/option> option valueVonvendi>VONVENDIsup>®/sup> von Willebrand factor (Recombinant)/option> /select> div classerrorMsg>Select Product/div> /div> h2>Patient Information/h2> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>First Namesup>*/sup>/label> input typetext classform-control idcrx-wl-firstName namePatientFirstName onkeyDownreturn allowSpaceAlphebets(crx-wl-firstName,event);> div classerrorMsg>Enter First Name/div> /div> /div> div classcol-md-4> div classfieldWrap crx-wl-question> label>Last Namesup>*/sup>/label> input typetext classform-control idcrx-wl-lastName namePatientLastName onkeyDownreturn allowSpaceAlphebets(crx-wl-lastName,event);> div classerrorMsg>Enter Last Name/div> /div> /div> div classcol-md-4> div classfieldWrap dobWrap crx-wl-question> label>Date of Birthsup>*/sup>/label> input typetext classform-control idcrx-wl-birthDate onfocusoutvalidateDOB();> img image-srccalendar-icon.png altCalendar classcrx-wl-image dobIcon> div classerrorMsg iderrorMsgDOB>Enter Date of Birth/div> /div> /div> /div> div classrow align-items-center> div classcol-md-4> div classfieldWrap custom-list dropDownMenu lessWideField crx-wl-question> label>Gendersup>*/sup>/label> select namegender idcrx-wl-gender namecrx-wl-gender> option>Select/option> option valuemale>MALE/option> option valuefemale>FEMALE/option> /select> div classerrorMsg>Select Gender/div> /div> /div> div classcol-md-8> div classinfoTxt> Takeda and its partners recognize that patients may not identify as male or female. However, many insurance companies still require that one of these two fields be used for each of their members. Please indicate the gender on file with the patient’s insurance company. /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Addresssup>*/sup>/label> input typetext classform-control idcrx-wl-addressLine1 namePatientStreetAddress1> div classerrorMsg>Enter Address/div> /div> /div> div classcol-md-4> div classfieldWrap crx-wl-question> label>Citysup>*/sup>/label> input typetext classform-control idcrx-wl-city namePatientCITY onkeyDownreturn allowSpaceAlphebets(crx-wl-city,event);> div classerrorMsg>Enter City/div> /div> /div> div classcol-sm-2 stateZipWrap> div classfieldWrap crx-wl-question stateListNew custom-list dropDownMenu> label>Statesup>*/sup>/label> select namestate idcrx-wl-state data-option-textvalue data-option-valuevalue data-default-textSelect> option value>Select/option> /select> div classerrorMsg>Select State/div> /div> /div> div classcol-sm-2 stateZipWrap> div classfieldWrap crx-wl-question> label>ZIPsup>*/sup>/label> input typetext classform-control idcrx-wl-zip namePatientZip minlength5 maxlength5> div classerrorMsg>Enter ZIP/div> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Emailsup>*/sup>/label> input typetext classform-control idcrx-wl-email namePatientEmail> div classerrorMsg>Enter Email/div> /div> /div> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question> label>Primary Phonesup>*/sup>/label> input typetext classform-control phoneField idcrx-wl-phone namePatientPhone maxlength12 onkeyDownreturn validatePhone(crx-wl-phone,event);> div classerrorMsg>Enter Primary Phone/div> /div> /div> div classcol-md-4> div classfieldWrap lessWideField custom-list dropDownMenu> label>Phone Typesup>*/sup>/label> select namephoneType idcrx-wl-phoneType> option>Select/option> option valuehome>HOME/option> option valuemobile>MOBILE/option> /select> div classerrorMsg>Select Phone Type/div> /div> /div> /div> h2 classmt-2>Does this patient have a Legal Representative?sup>*/sup>/h2> div classfieldWrap> div classradioWrap idcrx-wl-legalRep> div classradioBtn> input typeradio namerepresentative idrepresentative-yes valueyes> label forrepresentative-yes>Yes/label> /div> div classradioBtn> input typeradio namerepresentative idrepresentative-no valueno> label forrepresentative-no>No/label> /div> /div> div classerrorMsg>Make a selection/div> /div> div classrepresentativeWrap hideElement> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Legal Representative First Namesup>*/sup>/label> input typetext classform-control idcrx-wl-caregiver-firstName onkeyDownreturn allowSpaceAlphebets(crx-wl-caregiver-firstName,event);> div classerrorMsg>Enter Legal Representative First Name/div> /div> /div> div classcol-md-4> div classfieldWrap crx-wl-question> label>Legal Representative Last Namesup>*/sup>/label> input typetext classform-control idcrx-wl-caregiver-lastName onkeyDownreturn allowSpaceAlphebets(crx-wl-caregiver-lastName,event);> div classerrorMsg>Enter Legal Representative Last Name/div> /div> /div> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question custom-list dropDownMenu> label>Relationship to Patientsup>*/sup>/label> select namecaregiverRelationship idcrx-wl-caregiver-relationship> option>Select/option> option valueSpouse>SPOUSE/option> option valueDomestic Partner>DOMESTIC PARTNER/option> option valueSignificant Other>SIGNIFICANT OTHER/option> option valueSibling>SIBLING/option> option valueChild>CHILD/option> option valueParent>PARENT/option> option valueGrandparent>GRANDPARENT/option> option valueGrandchild>GRANDCHILD/option> option valueAunt/Uncle>AUNT/UNCLE/option> option valueNiece/Nephew>NIECE/NEPHEW/option> option valueFriend>FRIEND/option> option valueOther>OTHER/option> /select> div classerrorMsg>Select Relationship to Patient/div> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Legal Representative Emailsup>*/sup>/label> input typetext classform-control idcrx-wl-caregiver-email> div classerrorMsg>Enter Legal Representative Email/div> /div> /div> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question> label>Legal Representative Phonesup>*/sup>/label> input typetext classform-control phoneField idcrx-wl-caregiver-homePhone maxlength12 onkeyDownreturn validatePhone(crx-wl-caregiver-homePhone,event);> div classerrorMsg>Enter Legal Representative Phone/div> /div> /div> div classinsuranceBox> div> input typecheckbox nameinsurance idcrx-wl-dependent> label forcrx-wl-dependent> I hereby attest that I am the legal representative of the patient and have the necessary legal authority to act on their behalf. I understand that providing false information may result in the termination of enrollment and potential legal consequences./label> div classerrorMsg>Required/div> /div> /div> /div> /div> div classbtnWrap> button classcontinueBtn btn-submit idbtnNextPatientInfo val-fileclient onclicktrimInputTextFields(patientInfo); cl-handlerpatientInfoSubmit>CONTINUEdiv classarrow>/div>/button> /div> /div> /div> div classenrollSteps step2 hideElement idinsuranceInfo> div classwelcomeWrap> h1>Takeda Patient Support Enrollment Form/h1> /div> div classprogressBar> ul> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classactive> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> /li> /ul> /div> div classformWrap> img image-srcstep2-icon.png altInsurance classcrx-wl-image stepIcon> h2>Insurance/h2> div classinsuranceBox> input typecheckbox nameinsurance idinsurance> label forinsurance>Please check this box if the patient does not have insurance./label> /div> h3>Primary Insurance/h3> div classrow> div classcol-md-4> div classfieldWrap> label>Primary Insurancesup>*/sup>/label> input typetext classform-control idcrx-wl-ins-pi-payerName maxlength250> div classerrorMsg>Enter Primary Insurance/div> /div> /div> div classcol-md-4> div classfieldWrap > label>Policyholder Namesup>*/sup>/label> input typetext classform-control idcrx-wl-ins-pi-policyHolderName onkeyDownreturn allowSpaceAlphebets(crx-wl-pi-policyHolderName,event);> div classerrorMsg>Enter Policyholder Name/div> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap lessWideField> label>Policy ID #sup>*/sup>/label> input typetext classform-control idcrx-wl-ins-pi-memberId maxlength20> div classerrorMsg>Enter Policy ID #/div> /div> /div> div classcol-md-4> div classfieldWrap lessWideField> label>Group #sup>*/sup>/label> input typetext classform-control idcrx-wl-ins-pi-groupNumber maxlength15> div classerrorMsg>Enter Group #/div> /div> /div> /div> h3 classmt-2>Secondary Insurance/h3> div classrow> div classcol-md-4> div classfieldWrap> label>Secondary Insurance/label> input typetext classform-control idcrx-wl-ins-si-payerName maxlength250> /div> /div> div classcol-md-4> div classfieldWrap> label>Policyholder Name/label> input typetext classform-control idcrx-wl-ins-si-policyHolderName onkeyDownreturn allowSpaceAlphebets(crx-wl-si-policyHolderName,event);> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap lessWideField> label>Policy ID #/label> input typetext classform-control idcrx-wl-ins-si-memberId maxlength20> /div> /div> div classcol-md-4> div classfieldWrap lessWideField> label>Group #/label> input typetext classform-control idcrx-wl-ins-si-groupNumber maxlength15> /div> /div> /div> h3 classmt-2>Pharmacy Plan/h3> div classrow> div classcol-md-4> div classfieldWrap> label>Pharmacy Plan Name/label> input typetext classform-control idcrx-wl-ins-pp-payerName maxlength250> /div> /div> div classcol-md-4> div classfieldWrap lessWideField> label>Policy ID #/label> input typetext classform-control idcrx-wl-ins-pp-memberId maxlength20> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap lessWideField> label>Policy Group #/label> input typetext classform-control idcrx-wl-ins-pp-groupNumber maxlength15> /div> /div> div classcol-md-4> div classfieldWrap lessWideField> label>Rx BIN #/label> input typetext classform-control idcrx-wl-ins-pp-bin maxlength6> /div> /div> div classcol-md-4> div classfieldWrap lessWideField> label>Rx PCN #/label> input typetext classform-control idcrx-wl-ins-pp-pcn maxlength10> /div> /div> /div> div classbtnWrap> button classbackBtn onclickreturn RedirectTo(toPatient,back);>div classarrow>/div>BACK/button> button classcontinueBtn btn-submit idbtnNextInsuranceInfo onclicktrimInputTextFields(insuranceInfo); cl-handlerinsuranceInfoSubmit>CONTINUEdiv classarrow>/div>/button> /div> /div> /div> div classenrollSteps step3 hideElement idprescriberInfo> div classwelcomeWrap> h1>Takeda Patient Support Enrollment Form/h1> /div> div classprogressBar> ul> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classactive> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> /li> /ul> /div> div classformWrap> img image-srcstep3-icon.png altPrescriber Information classcrx-wl-image stepIcon> h2>Prescriber Information/h2> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Prescriber First Namesup>*/sup>/label> input typetext classform-control idcrx-wl-prescribingPhysician-firstName onkeyDownreturn allowSpaceAlphebets(crx-wl-prescribingPhysician-firstName,event);> div classerrorMsg>Enter Prescriber First Name/div> /div> /div> div classcol-md-4> div classfieldWrap crx-wl-question> label>Prescriber Last Namesup>*/sup>/label> input typetext classform-control idcrx-wl-prescribingPhysician-lastName onkeyDownreturn allowSpaceAlphebets(crx-wl-prescribingPhysician-lastName,event);> div classerrorMsg>Enter Prescriber Last Name/div> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Facility Name/label> input typetext classform-control idcrx-wl-referralPractice-name> /div> /div> div classcol-md-4> div classfieldWrap> label>Office Contact/label> input typetext classform-control idcrx-wl-officeContact onkeyDownreturn allowSpaceAlphebets(crx-wl-officeContact,event);> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question> label>Facility Tax ID/label> input typetext classform-control idcrx-wl-referralPractice-taxId maxlength10 onkeyDownreturn validateTaxId(crx-wl-referralPractice-taxId,event);> /div> /div> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question> label>Facility NPI/label> input typetext classform-control idcrx-wl-referralPractice-npi maxlength10> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Facility Address/label> input typetext classform-control idcrx-wl-referralPractice-addressLine1> /div> /div> div classcol-md-4> div classfieldWrap crx-wl-question> label>City/label> input typetext classform-control idcrx-wl-referralPractice-city onkeyDownreturn allowSpaceAlphebets(crx-wl-referralPractice-city,event);> /div> /div> div classcol-sm-2 stateZipWrap> div classfieldWrap custom-list stateListNew dropDownMenu crx-wl-question> label>State/label> select namereferralPracticeState idcrx-wl-referralPractice-state classcrx-wl-state data-option-textvalue data-option-valuevalue data-default-textSelect> option value>Select/option> option value>Select/option> /select> /div> /div> div classcol-sm-2 stateZipWrap> div classfieldWrap crx-wl-question> label>ZIP/label> input typetext classform-control idcrx-wl-referralPractice-postalCode minlength5 maxlength5> /div> /div> /div> div classrow> div classcol-md-4> div classfieldWrap crx-wl-question> label>Email/label> input typetext classform-control idcrx-wl-referralPractice-email> /div> /div> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question> label>Phone/label> input typetext classform-control phoneField idcrx-wl-referralPractice-phone maxlength12 onkeyDownreturn validatePhone(crx-wl-referralPractice-phone,event);> /div> /div> div classcol-md-4> div classfieldWrap lessWideField crx-wl-question> label>Fax/label> input typetext classform-control phoneField idcrx-wl-referralPractice-fax maxlength12 onkeyDownreturn validatePhone(crx-wl-referralPractice-fax,event);> /div> /div> /div> div classbtnWrap> button classbackBtn onclickreturn RedirectTo(toInsurance,back);>div classarrow>/div>BACK/button> button classcontinueBtn btn-submit idbtnNextPrescriberInfo val-fileprescriber onclicktrimInputTextFields(prescriberInfo); cl-handlerprescriberInfoSubmit>CONTINUEdiv classarrow>/div>/button> /div> /div> /div> div classenrollSteps step4 hideElement idacknowledgeInfo> div classwelcomeWrap> h1>Takeda Patient Support Enrollment Form/h1> /div> div classprogressBar> ul> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classactive> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> /li> /ul> /div> div classformWrap> img image-srcstep4-icon.png altAcknowledge classcrx-wl-image stepIcon> h2>Acknowledge/h2> h4>Please review the following and acknowledge to proceed./h4> div classacknowledgeWrap authWrap> h5>Patient HIPAA Authorization/h5> p>By signing the Patient Authorization section of this 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 Takeda Patient Support Program (the “Companies”). The Companies will use my Protected Health Information for the purpose of facilitating the provision of the Takeda 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 support, 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 the Takeda Patient Support Program and contact me, and/or the person legally authorized to sign on my behalf, about the Takeda Patient Support Program; 2) provide me, and/or the person legally authorized to sign on my behalf, with educational materials, information, and services related to the Takeda Patient Support Program; 3) verify, investigate, and provide information about my coverage, 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./p> p>I understand that employees of the Companies only use my Protected Health Information for the purposes described herein, to administer the Takeda 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 revoke this Authorization and that instructions for doing so are contained in Takeda’s Website Privacy Notice available at a hrefjavascript:void(0); redirhttps://www.takeda.com/privacy-notice/ classcrx-wl-redirect-new>www.takeda.com/privacy-notice//a> or I may revoke this Authorization at any time by sending written notice of revocation to the Takeda Patient Support Program, PO Box 2355, Morristown, NJ 07962. I understand that such revocation will not apply to any information already used or disclosed through this Authorization. This Authorization will expire at the earliest of what is required by state law, and never in any case longer than 5 years. I also understand that if I do not sign this Authorization, I will not be able to receive the Takeda Patient Support Program products, supplies, or services./p> div classinsuranceBox> input typecheckbox namehippa idcrx-wl-ack-hipaa> label forcrx-wl-ack-hipaa>Patient HIPAA Authorization: I have read, understand, and agree to the release of my protected health information as described above.sup>*/sup>/label> div classerrorMsg>Required/div> /div> div classchoiceWrap> label>Who is signing this consent?sup>*/sup>/label> div classradioWrap idcrx-wl-ack-hipaa-sign> div classradioBtn> input typeradio classackSign namehipaa-sign idhipaa-sign-patient valuePatient> label forhipaa-sign-patient>Patient/label> /div> div classradioBtn> input typeradio classackSign namehipaa-sign idhipaa-sign-representative valuecaregiver> label forhipaa-sign-representative>Legal Representative/label> /div> /div> div classerrorMsg idhipaa-sign-error>Make a selection/div> /div> div classrow> div classcol-md-4 crx-wl-question> h6>Signature*/h6> label>Type your signature./label> input typetext classform-control idcrx-wl-ack-hipaa-signature onkeyDownreturn allowSpaceAlphebets(crx-wl-ack-hipaa-signature,event);> div classerrorMsg>Signature required/div> /div> /div> div classrow> div classcol-md-4 mb-0 lessWideField> label>Date of Certification/label> input typetext classform-control currentDate disabled> /div> /div> /div> div classacknowledgeWrap serviceWrap> h5>Takeda Patient Support Services Enrollment/h5> p>By signing below, I am electing to enroll in Takeda Patient Support for Hematology Services (“Services”) and direct all disclosures of my Information in connection with such Services (which may include, but are not limited to, verification of insurance benefits and drug coverage, prior authorization support, financial assistance with co-pays, patient assistance programs, alternate funding sources, other related programs, communication with me or my prescribing physician by mail, email, or telephone about my medical condition, treatment, care management, product information, and health insurance)./p> div classinsuranceBox> input typecheckbox nameservice-enroll idcrx-wl-ack-service> label forcrx-wl-ack-service>Takeda Patient Support Services Enrollment: I agree to be enrolled in product support services through Takeda Patient Support.sup>*/sup>/label> div classerrorMsg>Required/div> /div> div classchoiceWrap> label>Who is signing this consent?sup>*/sup>/label> div classradioWrap idcrx-wl-ack-service-sign> div classradioBtn> input typeradio classackSign nameservice-sign idservice-sign-patient valuePatient> label forservice-sign-patient>Patient/label> /div> div classradioBtn> input typeradio classackSign nameservice-sign idservice-sign-representative valuecaregiver> label forservice-sign-representative>Legal Representative/label> /div> /div> div classerrorMsg idservice-sign-error>Make a selection/div> /div> div classrow> div classcol-md-4 crx-wl-question> h6>Signature*/h6> label>Type your signature./label> input typetext classform-control idcrx-wl-ack-service-signature onkeyDownreturn allowSpaceAlphebets(crx-wl-ack-service-signature,event);> div classerrorMsg>Signature required/div> /div> /div> div classrow> div classcol-md-4 mb-0 lessWideField> label>Date of Certification/label> input typetext classform-control currentDate disabled> /div> /div> /div> div classacknowledgeWrap marketingWrap> h5>Marketing Communications OPTIONAL/h5> div classinsuranceBox marketingWrap> input typecheckbox namemarketing-consent idcrx-wl-ack-marketing> label forcrx-wl-ack-marketing>strong>Consent for Marketing Information:/strong> By checking the box, I authorize the use of my Information for Takeda marketing activities and consent to receiving marketing and promotional communications from Takeda. I hereby give consent to Takeda, its affiliates, and their agents and representatives to send communications and information to me via the contact information I have provided above. I understand that this consent will be in effect until I cancel such authorization./label> /div> /div> div classacknowledgeWrap smsWrap> h5>Text Messaging Agreement Terms & Conditions OPTIONAL/h5> p>By agreeing to these Takeda Patient Support Program (the “Program”) text message terms and conditions, you agree to receive text messages on your mobile device subject to the Terms & Conditions described below. You also consent to receive autodialed and/or pre-recorded calls and/or text messages from or on behalf of the Program at the telephone number provided above. You understand that this consent is not a condition of purchase or use of the Program or of any Takeda product or service. You can unsubscribe from receiving text messages by texting STOP. You will remain enrolled in Takeda Patient Support. For questions about this Program, text HELP or contact the customer support center at span classnoWrapTxt>888-229-8379./span>/p> p>Participants will receive an average of 5 text messages each month while enrolled in the Program. Such messages may be nonmarketing messages related to the Patient Support Program./p> p>There is no fee payable to Takeda to receive text messages; however, your carrier’s message and data rates may apply./p> p>You represent that you are the account holder for the mobile telephone number(s) that you provide to opt into the Program. You are responsible for notifying Takeda immediately if you change your mobile telephone number. You may notify Takeda of a number change by calling span classnoWrapTxt>888-229-8379./span>/p> p>Data obtained from you in connection with your registration for, and use of, this SMS service may include your phone number and/or email address, related carrier information, and elements of pharmacy claim information and will be used to administer this Program and to provide Program benefits such as information about your prescription, refill reminders, as well as Program updates and alerts./p> p>Takeda will not be liable for any delays in the receipt of any SMS messages as delivery is subject to effective transmission from your network operator./p> p>This Program is valid with most major U.S. carriers, including Verizon Wireless, Sprint, Nextel, Boost Mobile, T-Mobile®, AT&T, Alltel, ACS Wireless, Bluegrass Cellular, Carolina West Wireless, CellCom, Cellular One of East Central Illinois (ECIT), Cincinnati Bell, Cricket, C-Spire Wireless, Duet IP (aka Max/Benton/Albany), Element Mobile, Epic Touch, GCI Communications, Golden State, Hawkeye (Chat Mobility), Hawkeye (NW Missouri Cellular), Illinois Valley Cellular (IVC), Inland Cellular, iWireless, Keystone Wireless (Immis/PC Management), MetroPCS, MobiPCS, Mosaic, MTPCS/Cellular One (Cellone Nation), Nex-Tech Wireless, nTelos, Panhandle Telecommunications, Pioneer, Plateau, Revol Wireless, Rina-Custer, Rina-All West, Rina-Cambridge Telecom Coop, Rina-Eagle Valley Comm, Rina-Farmers Mutual Telephone Co, Rina-Nucla Nutria Telephone Co, Rina-Silver Star, Rina-South Central Comm, Rina-Syringa, Rina-UBET, Rina-Manti, Simmetry, South Canaan/CellularOne of NEPA, Thumb Cellular, Union Wireless, United Wireless, U.S. Cellular, Viaero Wireless, Virgin Mobile, and West Central Wireless (includes Five Start Wireless). By agreeing to these Takeda Patient Support Program (the “Program”) text message terms and conditions, you agree to receive text messages on your mobile device subject to the Terms & Conditions described below. You also consent to receive autodialed and/or pre-recorded calls and/or text messages from or on behalf of the Program at the telephone number provided above. You understand that this consent is not a condition of purchase or use of the Program or of any Takeda product or service. You can unsubscribe from receiving text messages by texting STOP. You will remain enrolled in the Takeda Patient Support Program. For questions about this Program, text HELP or contact the customer support center at span classnoWrapTxt>888-229-8379./span>/p> p>Participants will receive an average of 5 text messages each month while enrolled in the Program. Such messages may be nonmarketing messages related to the Patient Support Program./p> div classinsuranceBox> input typecheckbox namesms-enroll idcrx-wl-ack-sms> label forcrx-wl-ack-sms>Text Communication Enrollment: I have read, understand, and agree to opt-in for text communications as described above./label> /div> div classchoiceWrap> label>Who is signing this consent?sup>*/sup>/label> div classradioWrap idcrx-wl-ack-sms-consent> div classradioBtn> input typeradio classackSign namesms-consent idsms-patient valuePatient> label forsms-patient>Patient/label> /div> div classradioBtn> input typeradio classackSign namesms-consent idsms-representative valuecaregiver> label forsms-representative>Legal Representative/label> /div> /div> div classerrorMsg idsms-consent-error>Make a selection/div> /div> div classrow> div classcol-md-4 crx-wl-question> h6>Signature*/h6> label>Type your signature./label> input typetext classform-control idcrx-wl-ack-sms-signature onkeyDownreturn allowSpaceAlphebets(crx-wl-ack-sms-signature,event);> div classerrorMsg>Signature required/div> /div> /div> div classrow> div classcol-md-4 mb-0 lessWideField> label>Date of Certification/label> input typetext classform-control currentDate disabled> /div> /div> /div> div classbtnWrap mt-4> button classbackBtn onclickreturn RedirectTo(toPrescriberInformation,back);>div classarrow>/div>BACK/button> button classcontinueBtn btn-submit idbtnNextAcknowledgeInfo val-fileacknowledge cl-handleracknowledgeInfoSubmit onclicktrimInputTextFields(acknowledgeInfo);>CONTINUEdiv classarrow>/div>/button> /div> /div> /div> div classenrollSteps step5 hideElement ideligibilityInfo> div classwelcomeWrap> h1>Takeda Patient Support Enrollment Form/h1> /div> div classprogressBar> ul> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classactive> div classcircle>/div> div classdivider>/div> /li> li> div classcircle>/div> /li> /ul> /div> div classformWrap> img image-srcstep5-icon.png altCo-pay Eligibility classcrx-wl-image stepIcon> h2>Co-pay Eligibility/h2> div classeligibilityQues> label>Is the patient span classnoWrapTxt>18/span> years of age or older?sup>*/sup>/label> div classradioWrap idcrx-wl-eli-age> div classradioBtn> input typeradio classeliFields nameage idage-yes valueYes> label forage-yes>Yes/label> /div> div classradioBtn> input typeradio classeliFields nameage idage-no valueNo> label forage-no>No/label> /div> /div> div classerrorMsg>Make a selection/div> /div> div classeligibilityQues> label>Is the patient a resident of the United States or its Territories?sup>*/sup>/label> div classradioWrap idcrx-wl-eli-resident> div classradioBtn> input typeradio classeliFields nameresident idresident-yes valueYes> label forresident-yes>Yes/label> /div> div classradioBtn> input typeradio classeliFields nameresident idresident-no valueNo> label forresident-no>No/label> /div> /div> div classerrorMsg>Make a selection/div> /div> div classeligibilityQues> label>Does the patient have commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace.sup>*/sup>/label> div classradioWrap idcrx-wl-eli-commIns> div classradioBtn> input typeradio classeliFields namecommIns idcomm-ins-yes valueYes> label forcomm-ins-yes>Yes/label> /div> div classradioBtn> input typeradio classeliFields namecommIns idcomm-ins-no valueNo> label forcomm-ins-no>No/label> /div> /div> div classerrorMsg>Make a selection/div> /div> div classeligibilityQues> label>Is the patient’s prescription covered in part or full under any state or federally funded programs such as Medicare (including Medicare Part D and Medicare Advantage), Medicaid, Medigap, VA, DoD, State Pharmacy Assistance, TRICARE, etc?sup>*/sup>/label> div classradioWrap idcrx-wl-eli-medicare> div classradioBtn> input typeradio classeliFields namemedicare idmedicare-yes valueYes> label formedicare-yes>Yes/label> /div> div classradioBtn> input typeradio classeliFields namemedicare idmedicare-no valueNo> label formedicare-no>No/label> /div> /div> div classerrorMsg>Make a selection/div> /div> div classeligibilityQues> label>Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Takeda Patient Support for Hematology Co-pay program?sup>*/sup>/label> div classradioWrap idcrx-wl-eli-support> div classradioBtn> input typeradio classeliFields namesupport idsupport-yes valueYes> label forsupport-yes>Yes/label> /div> div classradioBtn> input typeradio classeliFields namesupport idsupport-no valueNo> label forsupport-no>No/label> /div> /div> div classerrorMsg>Make a selection/div> /div> div classacknowledgeWrap authWrap> h5>Co-Pay Acknowledgment (Terms and Conditions)/h5> p>Takeda’s Co-pay Assistance Program (“the Program”) provides financial support for commercially insured patients who qualify for the Program. Participation in the Program and provision of financial support is subject to all Program terms and conditions, including but not limited to eligibility requirements, the Program maximum benefit per claim and the annual calendar year Program maximum (“Annual Program Maximum”). The Annual Program Maximum for your prescribed Takeda product can be found by visiting: a hrefjavascript:void(0); redirhttps://www.takedapatientsupport.com/hematology classcrx-wl-redirect-new>https://www.takedapatientsupport.com/hematology/a>./p> p>By enrolling in the Program, you agree that the Program is intended solely for the benefit of you—not health plans and/or their partners. Further, you agree to comply with all applicable requirements of your health plan. The Program cannot be used if the 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 the patient is currently in the coverage gap, or 3) insurance that is paying the entire cost of the prescription. No claim for reimbursement of the out-of-pocket expense amount covered by the Program shall be submitted to any third-party payer, whether public or private./p> p>Some health plans have established programs referred to as ‘co-pay maximizer’ programs. A co-pay maximizer program is one in which the amount of a patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a manufacturer’s co-pay assistance program. If you are enrolled in a co-pay maximizer program, your Annual Program Maximum may vary over time to ensure the program funds are used for your benefit (for the benefit of the patient). Takeda also reserves the right to reduce or eliminate the co-pay assistance available to patients enrolled in an insurance plan that utilizes a co-pay maximizer program./p> p>If you learn your health plan has implemented a co-pay maximizer program, you agree to notify the Program immediately by calling span classnoWrapTxt>1-888-229-8379./span> It may be possible that you are unaware whether you are subject to a co-pay maximizer program when you enroll or re-enroll in the Program. Takeda will monitor program utilization data and reserves the right to discontinue assistance under the Program at any time if Takeda determines that you are subject to a co-pay maximizer, or similar program./p> p>The 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 the Program immediately at span classnoWrapTxt>1-888-229-8379./span> Coverage of certain administration charges will not apply for patients residing in states where it is prohibited by law./p> p>This Program 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, co-pay maximizer, alternative funding program, copay accumulator, or other offer, including those from third parties and companies that help insurers or health plan manage costs. Not valid if reproduced./p> p>By utilizing the Program, you hereby accept and agree to abide by these terms and conditions. Any individual or entity who enrolls or assists in the enrollment of a patient in the Program represents that the patient meets the eligibility criteria and other requirements described herein. You must meet the Program eligibility requirements every time you use the Program. Takeda reserves the right to rescind, revoke, or amend the Program at any time without notice, and other terms and conditions may apply./p> div classchoiceWrap> label>Who is signing this consent?sup>*/sup>/label> div classradioWrap idcrx-wl-eli-progAcc> div classradioBtn> input typeradio classeliFields nameprogAcc idprog-acc-patient valuePatient> label forprog-acc-patient>Patient/label> /div> div classradioBtn> input typeradio classeliFields nameprogAcc idprog-acc-representative valuecaregiver> label forprog-acc-representative>Legal Representative/label> /div> /div> div classerrorMsg idprogAcc-error>Make a selection/div> /div> div classrow> div classcol-md-4 crx-wl-question> h6>Signature*/h6> label>Type your signature./label> input typetext classform-control idcrx-wl-eli-progAcc-signature onkeyDownreturn allowSpaceAlphebets(crx-wl-eli-progAcc-signature,event);> div classerrorMsg>Signature required/div> /div> /div> div classrow> div classcol-md-4 mb-0 lessWideField> label>Date of Certification/label> input typetext classform-control currentDate disabled> /div> /div> /div> div classbtnWrap mt-4> button classbackBtn onclickreturn RedirectTo(toAcknowledge,back);>div classarrow>/div>BACK/button> button classcontinueBtn btn-submit val-fileeligibility idbtnNextEligibilityInfo cl-handlereligibilityInfoSubmit onclicktrimInputTextFields(eligibilityInfo);>CONTINUEdiv classarrow>/div>/button> /div> /div> /div> div classenrollSteps step6 hideElement idreviewInfo> div classwelcomeWrap> h1>Takeda Patient Support Enrollment Form/h1> /div> div classprogressBar> ul> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classcompleted> div classcircle>/div> div classdivider>/div> /li> li classactive> div classcircle>/div> /li> /ul> /div> div classformWrap> img image-srcstep6-icon.png altReview classcrx-wl-image stepIcon> h2>Review/h2> p>Please review the information below and confirm accuracy before submitting./p> div classrow idpatientInfo> div classcol-12> h5>Patient Information/h5> /div> div classcol-3 reviewField50> span>First Name/span> strong idptFirstName>/strong> /div> div classcol-3 reviewField50> span>Last Name/span> strong idptLastName>/strong> /div> div classcol-3 reviewField50> span>Date of Birth/span> strong idptDOB>/strong> /div> div classcol-3 reviewField50 textCapitalize> span>Gender/span> strong idptGender>/strong> /div> div classcol-3 reviewField50> span>Address/span> strong idptAddress>/strong> /div> div classcol-3 reviewField50> span>City/span> strong idptCity>/strong> /div> div classcol-3 reviewField50> span>State/span> strong idptState>/strong> /div> div classcol-3 reviewField50> span>ZIP/span> strong idptZIP>/strong> /div> div classcol-3 reviewField100> span>Email/span> strong idptEmail>/strong> /div> div classcol-3 reviewField33> span>Primary Phone/span> strong idptPhone>/strong> /div> div classcol-3 reviewField33 textCapitalize> span>Phone Type/span> strong idptPhoneType>Mobile/strong> /div> div classcol-3 reviewField33> span>SMS Consent/span> strong idsmsConsent>/strong> /div> /div> div classrow idlegalRepresentative> div classcol-12> h5>Legal Representative Information/h5> /div> div classcol-3 lrNone> strong>None/strong> /div> div classcol-3 lrValue reviewField33> span>First Name/span> strong idlrFirstName>/strong> /div> div classcol-3 lrValue reviewField33> span>Last Name/span> strong idlrLastName>/strong> /div> div classcol-6 lrValue reviewField33 textCapitalize> span>Relationship/span> strong idlrRelationship>/strong> /div> div classcol-3 lrValue reviewField100> span>Email/span> strong idlrEmail>/strong> /div> div classcol-3 lrValue reviewField100> span>Phone/span> strong idlrPhone>/strong> /div> /div> div classrow idprimaryInsurance> div classcol-12> h5>Insurance/h5> /div> div classcol-3 piNone> strong>None/strong> /div> div classcol-3 piValue reviewField50> span>Primary Insurance/span> strong idpiPayerName>/strong> /div> div classcol-3 piValue reviewField50> span>Policyholder Name/span> strong idpiPolicyHolderName>/strong> /div> div classcol-3 piValue reviewField50> span>Policy ID #/span> strong idpiMemberId>/strong> /div> div classcol-3 piValue reviewField50> span>Group #/span> strong idpiGroupNumber>/strong> /div> /div> div classrow idsecondaryInsurance> div classcol-12 mb-0> h5 classmb-0>Secondary Insurance/h5> /div> div classcol-3 siNone> strong>None/strong> /div> div classcol-3 siValue reviewField50> span>Secondary Insurance/span> strong idsiPayerName>/strong> /div> div classcol-3 siValue reviewField50> span>Policyholder Name/span> strong idsiPolicyHolderName>/strong> /div> div classcol-3 siValue reviewField50> span>Policy ID #/span> strong idsiMemberId>/strong> /div> div classcol-3 siValue reviewField50> span>Group #/span> strong idsiGroupNumber>/strong> /div> /div> div classrow idpharmacyPlan> div classcol-12> h5>Pharmacy Plan/h5> /div> div classcol-12 ppNone> strong>None/strong> /div> div classcol-3 ppValue reviewField50> span>Pharmacy Plan Name/span> strong idppPayerName>/strong> /div> div classcol-9 ppValue reviewField50> span>Policy ID #/span> strong idppMemberId>/strong> /div> div classcol-3 ppValue reviewField33> span>Policy Group #/span> strong idppGroupNumber>/strong> /div> div classcol-3 ppValue reviewField33> span>Rx BIN #/span> strong idppBin>/strong> /div> div classcol-3 ppValue reviewField33> span>Rx PCN #/span> strong idppPcn>/strong> /div> /div> div classrow idprescriberInfo> div classcol-12> h5>Prescriber Information/h5> /div> div classcol-3 reviewField50> span>First Name/span> strong idpiFirstName>/strong> /div> div classcol-9 reviewField50> span>Last Name/span> strong idpiLastName>/strong> /div> div classcol-3 reviewField50> span>Facility Name/span> strong idrpName>/strong> /div> div classcol-9 reviewField50> span>Office Contact/span> strong idannOfficeContact>/strong> /div> div classcol-3 reviewField50> span>Tax ID #/span> strong idrpTaxId>/strong> /div> div classcol-9 reviewField50> span>NPI #/span> strong idrpNpi>/strong> /div> div classcol-3 reviewField50> span>Address/span> strong idrpAddress>/strong> /div> div classcol-3 reviewField50> span>City/span> strong idrpCity>/strong> /div> div classcol-3 reviewField50> span>State/span> strong idrpState>/strong> /div> div classcol-3 reviewField50> span>ZIP/span> strong idrpZip>/strong> /div> div classcol-3 reviewField100> span>Email/span> strong idrpEmail>/strong> /div> div classcol-3 reviewField50> span>Phone/span> strong idrpPhone>/strong> /div> div classcol-3 reviewField50> span>Fax/span> strong idrpFax>/strong> /div> /div> div classbtnWrap mt-4> button classcontinueBtn printBtn onclickwindow.print(); return false;>PRINT PAGE/button> button classbackBtn onclickreturn RedirectTo(toEligibility,back);>div classarrow>/div>BACK/button> button classcontinueBtn btn-submit idbtnNextReviewInfo workflowResolveEnrollment cl-handlerreviewInfoSubmit srv-handlerenrollSubmitResponse>SUBMITdiv classarrow>/div>/button> a classbtn-submit idbtnEnrollmentSubmit cl-handlerenrollmentSubmitNoErrorCheck srv-handlerenrollSubmitResponse workflowEnrollment styledisplay:none;>/a> /div> p classcrx-wl-submit-result>/p> /div> /div> div classenrollSteps welcomeWrap ineligible hideElement idineligibleInfo> h1>Your application may not be eligible for our Co-pay Program/h1> div classcontactWrap> img image-srccontact-icon.png altContact classcrx-wl-image> p classw-100>You have enrolled into Takeda Patient Support for Hematology. While your application may not be eligible for the Co-pay Program, there are additional support services such as product access, educational resources and financial assistance that may be available to you. If you have questions, please contact Takeda Patient Support for Hematology at span classnoWrapTxt>1-888-229-8379./span>/p> /div> div classbtnWrap> button classbackBtn onclickreturn RedirectTo(toReview,back);>div classarrow>/div>Back/button> /div> /div> /div> /div> /section> footer> div classcontainer> div classfooterLogoWrap> img image-srctakeda-logo.png altTakeda Logo classcrx-wl-image> ul> li>a hrefjavascript:void(0); redirhttps://www.takeda.com/en-us/terms-of-use classcrx-wl-redirect-new>Terms of Use/a>/li> li>a hrefjavascript:void(0); redirhttps://www.takeda.com/privacy-notice classcrx-wl-redirect-new>Privacy Notice/a>/li> li>a hrefjavascript:void(0); redirhttps://www.takedapatientsupport.com/ classcrx-wl-redirect-new>Contact Us/a>/li> /ul> /div> p>This site is intended for US residents and governed by US laws and government regulations./p> p>span classnoWrapTxt>©2024/span> Takeda Pharmaceuticals U.S.A., Inc. span classnoWrapTxt>1-877-TAKEDA-7/span> span classnoWrapTxt>(1-877-825-3327)./span> All rights reserved. TAKEDAsup>®/sup>, the TAKEDA Logosup>®/sup>, and the TAKEDA Patient Support Logosup classtradeSup>™/sup> are trademarks or registered trademarks of Takeda Pharmaceutical Company Limited./p> p classnoWrapTxt>US-XMP-2770v5.0 08/25/p> /div> /footer> div classcrx-wl-redirect to-ineligible redirineligible styledisplay:none;>/div> div classcrx-wl-redirect to-cardinfo redirprint styledisplay:none;>/div>div classmodal fade idcrx-wl-address-modal> div classmodal-dialog modal-dialog-centered> div classmodal-content> div classmodal-header> h4 classmodal-title>/h4> button typebutton classclose data-dismissmodal>×/button> /div> div classmodal-body>/div> div classmodal-footer> button typebutton classbtn btn-secondary crx-wl-address-confirm-btn data-dismissmodal>/button> /div> /div> /div>/div>div classcrx-wl-options> {crx-wl-channel:web,crx-wl-survey-name:Survey v1.0.0,groupNumber:EC16327008,enableMergeAssociation:false,allBrandsGroup:Advate:EC16327001,Adynovate:EC16327002,Adzynma:EC16327003,Feiba:EC16327004,Hemofil M:EC16327005,Recombinate:EC16327006,Rixubis:EC16327007,Vonvendi:EC16327008,resolveEnrollmentSearchFields:{patient.firstName:{},patient.lastName:{},patient.gender:{},patient.dob:{},patient.postalCode:{}},client:takeda,brand:hematology,brandPath:hematology,view:home}/div> /div>/body>/html>
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