Gammassist Form

Please Note All information and documentation obtained in relation to enrollment n Baxter s GAMMASSIST Program will be held in strict confidence by PAREXEL and will not be shared with Baxter or any other party. GammAssist Enrollment Form Enrollee Information Please Print Name Parent/Guardian Name if different Street Address City State E-mail Address THERAPY Social Security Number Zip Home Telephone Number Enrollee Date of Birth Therapy Start Date S/D IGIV IVEEGAM EN IGIV LIQUID IGIV POLYGAM S/D IGIV Average Monthly Usage DIAGNOSIS Immunodeficiency Syndromes B-cell Chronic Lymphocytic Leukemia CLL Kawasaki Syndrome Idiopathic Thrombocytopenic Purpura ITP Other Please Specify Health Insurance Information Primary Insurance Carrier Private Insurance Medicare Medicaid Telephone Number Subscriber Name Policy ID Physician Information Physician Name Product Provider Home Care Company Name of Provider Institution/Practice Name Hospital Out-pt ZIP Other Contact Name Enrollee s Authorization and Certification I verify that the information provided in this enrollment form is complete and accurate. I authorize PAREXEL an Independent Program Administrator to obtain medical and insurance coverage information as necessary to complete the enrollment process. I have read the conditions of the Program and understand eligibility for this Program is based on certain requirements including continuous use of verifying use from home healthcare companies and/or other distributors of Baxter s Immune Globulin Intravenous Human therapies. I understand that Baxter reserves the right to deny or approve any Program enrollment form and reserves the right to modify or discontinue the Program at any time. For redemption of certificates a control number will be assigned to each enrollee to assure confidentiality. Date Enrollee or Guardian Signature mandatory for enrollment Once the form is completed mail or fax to PAREXEL P. I authorize PAREXEL an Independent Program Administrator to obtain medical and insurance coverage information as necessary to complete the enrollment process. I have read the conditions of the Program and understand eligibility for this Program is based on certain requirements including continuous use of verifying use from home healthcare companies and/or other distributors of Baxter s Immune Globulin Intravenous Human therapies. I have read the conditions of the Program and understand eligibility for this Program is based on certain requirements including continuous use of verifying use from home healthcare companies and/or other distributors of Baxter s Immune Globulin Intravenous Human therapies. I understand that Baxter reserves the right to deny or approve any Program enrollment form and reserves the right to modify or discontinue the Program at any time. For redemption of certificates a control number will be assigned to each enrollee to assure confidentiality. Date Enrollee or Guardian Signature mandatory for enrollment Once the form is completed mail or fax to PAREXEL P.